Final evaluation report - Florida Department of Children ... Region Gap … · 26/6/2020 · FINAL EVALUATION REPORT | Contract LHZ68 services to meet their needs (Simms, Madelyn,

SOUTHERN REGION GAP ANALYSIS: FINAL EVALUATION REPORT

RESEARCH TEAM MELISSA JOHNSON

JOHN ROBST AREANA CRUZ CATHY SOWELL

AMY VARGO RENE ANDERSON

YARITZA CARMONA SOPHIE JAMES

Submitted to Florida Department of Children and Families on June 26, 2020

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FINAL EVALUATION REPORT | Contract LHZ68

Table of Contents

Introduction ....................................................................................................................................5

Background ..................................................................................................................................5

Purpose and Objectives ................................................................................................................7

Phase I: Service Utilization and Patterns ..................................................................................8

Phase II: Children’s Behavioral Health Service Needs ............................................................9

Phase III: Service Access, Capacity, and Coordination of Care ..............................................9

Phase IV: Determination of Gaps ...........................................................................................10

Study Context .........................................................................................................................10

Methods .........................................................................................................................................12

Administrative Data Analysis ....................................................................................................12

Florida Safe Families Network (FSFN)..................................................................................13

Lead Agency (Our Kids) ........................................................................................................14

Substance Abuse and Mental Health Information System (SAMHIS) ..................................15

Financial and Services Accountability Management System (FASAMS) .............................16

Medicaid Recipient, Claims, and Encounter Data ..................................................................17

All Funding Sources ...............................................................................................................19

Deriving the Final Sample ......................................................................................................20

Analysis ..................................................................................................................................21

Case Record Reviews ................................................................................................................22

Document Review ......................................................................................................................23

Interviews ...................................................................................................................................24

Focus Groups ..............................................................................................................................25

Surveys .......................................................................................................................................26

Provider Survey ......................................................................................................................26

Case Management Survey ......................................................................................................27

Results ...........................................................................................................................................28

Processes and Procedures for Identifying Children’s Behavioral Health Needs .......................28

Assessment Processes .............................................................................................................29

Care Coordination...................................................................................................................32

Documentation .......................................................................................................................38

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Mental and Behavioral Health Needs of Children in Licensed Care .........................................39

Child Characteristics...............................................................................................................40

Child Mental Health Assessments ..........................................................................................42

Child Welfare Assessments of Child Needs ...........................................................................44

Child Mental Health Diagnoses and Treatment Needs ..........................................................48

Mental Health and Behavioral Health Service Needs ............................................................51

Estimate of Overall Child Welfare Population Needs ............................................................53

Stakeholder Perceptions of Mental and Behavioral Health Needs .........................................55

Children’s Behavioral Health Service Array .............................................................................57

Description of Provider Network and Service Array .............................................................58

Stakeholder Perceptions of Service Availability and Accessibility .......................................64

Service utilization Patterns for Children in Licensed Care ........................................................74

Child Characteristics...............................................................................................................74

Behavioral Health Services .....................................................................................................79

Regression Results ................................................................................................................. 89

Medicaid Plan Enrollment and Service Utilization ................................................................91

Service Utilization based on Children’s Needs ......................................................................96

Discussion....................................................................................................................................100

Recommendations ......................................................................................................................106

References ....................................................................................................................................110

Appendix A: Data Collection Protocols ......................................................................................114

Appendix B: Mental health Assessments used by Behavioral Health providers .........................142

Appendix C: Evidence-Based Practices and Treatment Modalities ............................................146

Appendix D: Behavioral Health Provider Survey Results ...........................................................148

Appendix E: Case Manager Survey Results ................................................................................151

Appendix F: Definitions for Administrative Data Analysis ........................................................154

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List of Tables

Table 1. Descriptive Statistics for Initial FSFN Sample (n=4,855) ..............................................13

Table 2. Services Paid by Our Kids for Children in Out-of-Home Care ......................................15

Table 3. Behavioral Health Services Paid by DCF Substance Abuse and Mental Health Funds,

January 2016-September 2018 .......................................................................................................15


October 2018-December 2018 .......................................................................................................17

Table 5. Behavioral Health Services Paid by Medicaid Program, 01/2016-09/2018 ...................18

Table 6. Behavioral Health Services Paid by All Funding Sources, January 2016-December

2018................................................................................................................................................19

Table 7. Child Characteristics by Age Group ...............................................................................41

Table 8. Most Frequently Completed Mental/Behavioral Health Assessments by Age Group ...43

Table 9. Child Welfare Assessments Completed by Age Group ..................................................45

Table 10. Child Welfare Needs Assessment Ratings by Age Group ............................................47

Table 11. Children’s Mental Health Diagnoses by Age Group ....................................................48

Table 12. Children’s Service Needs Identified by Behavioral Health Providers .........................52

Table 13. Estimate of Child Mental and Behavioral Health Needs ..............................................54

Table 14. Outpatient Services Provided in the Southern Region ..................................................59

Table 15. Therapeutic Placement Services Provided in the Southern Region ..............................61

Table 16. Inpatient Services Provided in the Southern Region ....................................................62

Table 17. Final Sample Characteristics ........................................................................................74

Table 18. Diagnostic profile for children in sample .....................................................................76

Table 19. Final Sample Characteristics by County .......................................................................77

Table 20. Diagnostic Profile by County .......................................................................................78

Table 21. Number of Children Receiving Behavioral Health Services and Number of Encounters

by Service.......................................................................................................................................80

Table 22. Expenditures per user of service and per child .............................................................81

Table 23. Average Expenditures by Child Characteristics ...........................................................83

Table 24. Average Expenditures by Child Characteristics – Non-Residential Services ..............84

Table 25. Behavioral Health Expenditures by Diagnosis .............................................................86

Table 26. Behavioral Health Expenditures by Year of Child Welfare .........................................88

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Table 27. Behavioral Health Expenditures by Placement Type ...................................................88

Table 28. Regression Results: Determinants of Behavioral Health Expenditures ........................90

Table 29. Service Penetration and Utilization by Month and Medicaid Plan ...............................93

Table 30. Non-residential Service Penetration and Utilization by Month and Medicaid Plan ....94

Table 31. Inpatient/Residential Service Penetration and Utilization by Month and

Medicaid Plan ................................................................................................................................95

Table 32. Percentage of children that received any behavioral health service and average

expenditures ...................................................................................................................................96

Table 33. Service utilization by level of service need ..................................................................97

Table 34. Number of days until assessment..................................................................................98

Table 35. Number of days until first non-assessment service ..................................................... 98

Table 36. Number of days between services ................................................................................99

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Introduction

The following report presents the findings from a study of behavioral health services for

children in licensed foster care in Florida’s Southern Region, including Miami-Dade and Monroe

Counties. This study was carried out by a team of researchers at the University of South Florida

in response to a request from the Florida Department of Children and Families (DCF). The

overarching purpose of the study was to identify gaps in service capacity and provision and

inform the state of areas where there are critical needs or concerns requiring attention. The

report concludes with a set of recommendations to improve services for children in Florida’s

child welfare system.

Background

Children entering foster care have high rates of mental and behavioral health needs

compared to children not involved in the child welfare system (Kerns, et al., 2014). Studies have

found that 35 to 45 percent of children entering foster care had chronic or untreated physical

health conditions (Hillen & Gafson, 2015), and 40 to 80 percent of children in foster care exhibit

signs of mental health problems (Lehmann, Havik, Havik, & Heiervang, 2013; Sullivan & van

Zyl, 2008). This reflects a combination of factors including the physical and emotional effects of

maltreatment, the lack of preventative care, and in many cases, exposure to poverty. Many

children in foster care have experienced multiple, repeated traumatic events over a period of

time, commonly referred to as complex trauma, which may manifest in a wide array of emotional

and behavioral reactions among affected children, but are often poorly assessed or understood by

child welfare systems (Deutsch, Lynch, Zlotnik, Matone, Kreider, & Noonan, 2015; Oswald,

Fegert, & Goldbeck, 2010).

While the high rate of behavioral health needs among the foster care population is well

documented, considerable gaps persist in connecting these children to adequate and appropriate

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services to meet their needs (Simms, Madelyn, Battistelli, & Kaufman, 2018; Kerns, et al., 2014;

Sullivan & van Zyl, 2008). Assessment is one critical factor in linking children to needed

services. Both the Child Welfare League of America and the American Academy of Pediatrics

(AAP) recommend that all children entering foster care should receive a comprehensive mental

health evaluation (Barbel, 2020; Szilagyi, Rosen, Rubin, & Zlotnik, 2015; AAP, 2005). A

number of challenges, however, have been identified with regard to the implementation of these

recommendations. These include lack of systematic screening for trauma exposure, associated

symptoms, and other mental and behavioral health problems among children entering foster care

(Simms, Madelyn, Battistelli, & Kaufman, 2018; Briggs, et al., 2012; Greeson, et al., 2011), lack

of knowledge and experience with the child welfare population among community mental health

providers (Kerns, et al., 2014; Kerker & Dore, 2006), lack of specific guidance on behavioral

health screening procedures and assessment tools (Simms, Madelyn, Battistelli, & Kaufman,

2018; Jee, et al., 2010), and lack of training among caseworkers on identifying mental health

needs or how to apply screening and assessment results to case planning (Kerns, et al., 2014).

Additionally, children in foster care often face barriers in accessing behavioral health

services. Challenges documented in the literature include eligibility criteria that preclude

children from receiving services without a diagnosed disorder, restrictions set by Medicaid on

the number of sessions they will reimburse, limited number of providers who accept Medicaid,

multiple placement changes that disrupt continuity of care, and lack of training and expertise

among caseworkers to identify appropriate services, facilitate access to services and coordinate

children’s care (Lohr, et al., 2019; Kerns, et al., 2014; Inkelas & Halfon, 2002).

Studies on the relationship between mental health status and child welfare outcomes have

found that mental health problems play an important role in successful placement in foster care

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and the likelihood of reunification. For example, children with a mental health diagnosis spend a

longer time in out-of-home care (Tarren-Sweeney, 2017). Given the importance of mental health

problems in determining child welfare outcomes, it is crucial to examine the health care services

received by children and determine where gaps in services exist.

A number of studies have examined Medicaid-funded health care services received by

children in the foster care system. Medicaid-funded services are appropriate for analysis because

the majority of children in the foster care system are enrolled in the Medicaid program. Children

in the foster care system tend to use much higher levels of both physical and mental health

services than other children (Szilagyi, Rosen, Rubin, & Zlotnik, 2015; CMHS & CSAT, 2013;

Gen, Sommers, & Cohen, 2005). Landsverk (2017) and Harman, et al., (2000) found that

children in the foster care system have expenditures similar to children eligible for Medicaid due

to disability and much greater than children eligible due to Temporary Assistance for Needy

Families (TANF).

Purpose and Objectives

The body of research described points to several areas of potential unmet need and gaps

in mental and behavioral health services for children in the foster care system. These include the

need for clear policies and procedures, including the use of evidence-based practices, around the

assessment of need, coordination of care, and provision of behavioral health services for children

in foster care, as well as processes for monitoring the receipt of services and child outcomes.

Along these lines, the purpose of the current study was to assess current processes for identifying

children’s behavioral health needs and coordinating care, the existing behavioral health service

array and capacity, and behavioral health care service utilization among children who received

out-of-home care in the Southern Region of Florida to determine where gaps in services exist.

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The study specifically examines service provision and utilization during calendar years 2016 to

2018 and was carried out in four phases.

Phase I: Service Utilization and Patterns. The first phase of the study developed an

analysis of behavioral health services utilization and service patterns among children placed in

licensed foster care in Florida’s Southern Region. This study phase built upon previous research

described above, incorporating additional funding sources beyond Medicaid to provide a

comprehensive assessment of behavioral health service utilization. Specific research questions

for Phase I included the following:

1. What are the demographic and diagnostic characteristics of children and adolescents in

licensed foster care who used behavioral health services in Calendar Years 2016, 2017,

and 2018?

2. What are the mental health and substance use service utilization and service patterns?

For each child in the sample, we examined the behavioral health services received across

all sources [Substance Abuse and Mental Health Information System (SAMHIS),

Financial and Services Accountability Management System (FASAMS), Medicaid, and

the Community Based Care Lead Agency (CBC)].

3. What entities paid for what services? While services received across all sources is

important to the overall care received by a child, it is important to understand how the

provision of services varies across payers.

4. What are the specific utilization and service patterns for certain subgroups of children

that will be mutually identified by DCF and USF? For example, subgroups based on age

(0-5, 6-12, 13-18) have been identified by the Department as an area of interest.

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Phase II: Children’s Behavioral Health Service Needs. The purpose of this study

phase was to identify, describe, and understand children’s behavioral health service needs as

documented by behavioral health care service providers and child welfare service providers, and

assess the degree of consistency or discrepancy between the needs documented by behavioral

health and child welfare providers. The policies and processes established and used by

providers, the managed care organizations, and DCF to identify and document children’s

behavioral health service needs were also examined, as well as the perceptions of behavioral

health care providers regarding care coordination. Specific research questions that guided data

collection for this phase were as follows:

1. What are the behavioral health service needs of children in licensed foster care in the

Southern Region?

2. What assessment processes and tools are used to determine and document the behavioral

health care needs of children in licensed foster care in the Southern Region?

3. To what degree is there consistency between the behavioral health care service needs of

children in licensed foster as documented by behavioral health care service providers and

documented by child welfare?

Phase III: Services Access, Capacity, and Coordination of Care. The purpose of this

study phase was to determine the array of behavioral health services available to children in

licensed foster care, the capacity of local service providers, and the processes in place for

connecting children in care to these services. Specific research questions that guided this phase

of the study were as follows:

1. What behavioral health services are currently available in the Southern Region for

children in foster care?

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2. How many providers offer each identified service, and what is their service capacity?

(E.g. How many children can be served per year)?

3. What service delivery models are used? (E.g., Where and how are services provided?

What is the typical service intensity/dosage? What is the typical service duration?)

4. To what extent are services readily available and accessible to children in need? (E.g. Do

providers carry a waitlist, and if so, how long on average do children wait to initiate

services? What barriers may limit access to the service?)

5. What are the policies, procedures, and practices of the CBC Lead Agency and its

contracted case management agencies related to the coordination of care for children who

require behavioral health services?

Phase IV: Determination of Gaps. The final phase of the evaluation built upon the

previous study findings to assess the gaps in behavioral health services for children in licensed

foster care in the Southern Region. This phase of the study compared existing services and use

of psychotropic medications, evidence-based practices, program models, funders, and care

coordination to the estimates of what is needed in each of these areas. The purpose of the final

analysis was to identify gaps in behavioral health service delivery and capacity. Based on the

findings, a set of recommendations is offered at the conclusion of the report regarding how to fill

the gaps in behavioral health services including evidence-based practices, models of service

delivery that are community based, and care coordination strategies. The recommendations also

address capacity building requirements for the Southern Region, including training and technical

assistance, monitoring of service provision, and quality assurance strategies.

Study context. Florida’s Southern Region is large and diverse, comprised of Miami-

Dade and Monroe Counties. Miami-Dade County is geographically the third largest county in

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Florida in terms of land area, as well as the most populous county, with a population of roughly

2,761,581 (U.S. Census Bureau, 2018). It is racially and ethnically diverse, with approximately

65% of the population identified as Hispanic/Latino, and 18.9% identified as Black.

Additionally, about 51% of the population is foreign-born, the majority of whom are of Cuban or

other Latin American origins. The county suffers from higher-than-average poverty rates, with

approximately 17.2% of the overall population, and 22% of children under the age of 18, living

below the poverty line.

In contrast, Monroe County is quite rural and sparsely populated, with a population of

approximately 75,027 primarily residing in the Florida Keys (U.S. Census Bureau, 2018b). The

ethnic make-up of the county is primarily non-Hispanic White (65.8%), with approximately

24.9% of the population identified as Hispanic/Latino and 6.9% identified as Black. The county

is considerably wealthier compared to Miami-Dade, with roughly 12% of the population living in

poverty.

As might be expected given the size of its overall population, the Southern Region has a

considerable child welfare population, particularly in Miami-Dade County. Data from DCF

indicate that from 2016 to 2018, there were 5,291 children with 5,480 out-of-home care episodes

in the Southern Region. Child protective investigations are conducted by the Department of

Children and Families (DCF), but the remainder of child welfare services, including foster care

and case management services, are managed by the local Community-based Care (CBC) Lead

Agency, which was Our Kids of Miami-Dade/Monroe, Inc. during the focal period of 2016 to

2018, but recently transitioned to Citrus Family Care Network (CFCN). Given the size of the

foster care population and what is known about the high rates of mental health needs among

children in foster care, child welfare and mental health systems can easily become overwhelmed

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if they do not have adequate capacity or coordination to handle the level of need, resulting in

fragmented services and unmet needs for children in care.

Methods

To provide a comprehensive assessment of children’s behavioral health needs, service

array, coordination of care, and service utilization, a mixed-method approach was used,

triangulating data from a variety of primary and secondary sources. Prior to beginning data

collection, the study protocol was submitted for review by the Institutional Review Board (IRB)

at USF and received exempt status due to the nature of work being classified as evaluation.

Regardless, all procedures were carried out in accordance with the ethical standards of the

University’s IRB and with the 1964 Helsinki declaration and its later amendments or comparable

ethical standards for the protection of human subjects. The protection and confidentiality of

study subjects was prioritized throughout the conduct of the study, including compliance with all

HIPPA requirements. The methods for data collection and analysis are laid out below. Copies

of data collection protocols are contained in Appendix A.

Administrative Data Analysis

Behavioral health care utilization and patterns of services were examined through

analysis of administrative data. The study included children in Miami-Dade and Monroe

Counties who received licensed child welfare out-of-home care at any point in calendar years

2016 to 2018 and received at least one publicly-funded behavioral health service while in out-of-

home care. Several data sources were used to identify children for the sample, which include

DCF’s automated child welfare information system – Florida Safe Families Network (FSFN), the

CBC Lead Agency, Substance Abuse and Mental Health Information System, Financial and

Services Accountability Management System, and Medicaid.

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Florida Safe Families Network (FSFN). FSFN data was used to identify youth who

received out-of-home child welfare services in Calendar Year (CY) 2016-2018 in the Southern

Region (n=5,291 children with 5,480 out-of-home episodes). Records with missing Social

Security Numbers were excluded (n=250). We also excluded out-of-home care episodes that

were less than 30 days in length (n=190). The remaining 5,022 out-of-home care episodes

comprised the initial sample for the analysis (4,855 children with 167 having multiple out-of-

home care stays).

Sample descriptive statistics are provided in Table 1. The sample averages 7.3 years old

and is almost equally divided between boys and girls. Over half the sample is Black and comes

from a single parent family. Sexual or physical abuse is reported for 17.9% of children, while

absence of care is the most common reason for child welfare services. Absence of care can

include a parent (or parents) being sent to prison, the death of a parent, or the parent

relinquishing custody. Ninety-five percent of the sample lives in Miami-Dade County.

Table 1. Descriptive Statistics for Initial FSFN Sample (n=4,855) Number of children % of sample/Mean

Age 4,855 7.34 Child gender Female 2,468 50.8 Male 2,387 49.2 Child race Black 2,633 54.2 White 2,007 41.3 Other 215 4.5 Family Structure Married Couple 488 10.0 Single Female 2,591 53.4 Single Male 214 4.4 Unmarried Couple 1,120 23.1 Unable to determine 442 9.1

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Type of Maltreatment Sexual abuse 202 4.2 Physical abuse 605 12.5 Neglect 1,702 35.1 Absence of care 2,069 42.6 Domestic violence 720 14.8 Substance abuse problems 1,508 31.1 County Miami-Dade 4,604 94.8 Monroe 251 5.2

Behavioral health service data was extracted from lead agency data, DCF Substance

Abuse and Mental Health funding data, and Medicaid data. Almost all youth entering out-of-

home child welfare services were Medicaid eligible, and the Medicaid program provided most

behavioral health services used by children. However, DCF Substance Abuse and Mental Health

funds and lead agency funds covered services not covered by Medicaid or not approved by

Medicaid managed care plans.

Lead Agency (Our Kids). The lead agency for the Southern Region, Our Kids, paid for a

portion of services needed by children. Of the 4,109 records for services paid by Our Kids

during CY 2016-2018, 3,418 were provided to 607 children in our sample1. Table 2 contains a

summary of the services paid by Our Kids included in this analysis. The most frequently

provided service was Certified Behavior Analysis, while expenditures were highest for in-home

respite services. The lead agency was the primary funder for alternative therapies such as

Motivational Edge (an arts-based educational program), dance therapy, martial arts and

summer/winter camps.

1 Data provided by Our Kids were aggregated into monthly records for each type of service provided to a child. Thus, the child may have received the service numerous times in the month, and the number of records is not equivalent to the number of services received by a child. Available data cannot be used to examine the cost per unit of service.

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Table 2. Services Paid by Our Kids for Children in Out-of-Home Care Services Number of children Number of Records for

Services Provided Total

expenditures In-home Respite Services 163 504 1,930,812 Certified Behavior Analysis 242 1,477 722,212 WRAP 45 108 449,205 Motivational Edge 44 338 293,532 STFC Clinical Services 21 81 177,836 Extracurricular/Incidentals/Miscellaneous 51 155 141,120 SIPP Clinical Services <10 19 123,400 Therapeutic Visitation 119 326 90,932 Functional Behavior Assessment 133 141 66,270 Individual Therapy 10 42 22,019 Other (e.g., CBHA, dance, martial arts, therapeutic service items, tutoring) 122 227 125,136

Total 607 3,418 4,142,474 Note. Sample sizes less than 10 are suppressed to maintain child confidentiality.

Substance Abuse and Mental Health Information System (SAMHIS). Behavioral

health service data from January 2016 – September 2018 was extracted for the sample (n=15,583

service encounters). Behavioral health services were limited to those provided during out-of-

home services (n=8,725 service encounters for 439 children). As reported in Table 3, total

expenditures were $541,794. The cost center with the most encounters and highest expenditures

was in-home and on-site services overlay (3,067 service encounters totaling $155,158).2


January 2016-September 2018 Cost Center Description Number of children Number of encounters Total Expenditures Assessment 342 736 42,708 Case Management 37 589 21,953 Crisis Stabilization 40 197 57,507 Crisis Support/Emergency 24 69 1,952

2 See Appendix 1 for a full description of each cost center.

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In-Home and On-Site Services Overlay 91 3,067 155,158 Inpatient <10 <10 3,145 Intensive Case Management <10 <10 54 Intervention 69 1,102 40,548 Medical 10 18 1,727 Outpatient-Individual 39 746 34,765 Residential Level 1 <10 12 2,749 Residential Level 2 <10 420 65,302 Residential Level 4 <10 279 13,459 Substance Abuse Detoxification 31 199 43,769 TASC <10 41 1,383 Incidental Expenses <10 <10 1,149 Aftercare/Follow-up <10 68 3,267 Outpatient-Group <10 <10 57 Room & Board Level 2 <10 147 16,309 Intervention-Group 10 309 6,336 MH Comprehensive-Individual 25 647 25,445 SA Recovery Support-Individual <10 <10 211 SA Recovery Support-Group <10 <10 45 Total 439 8,725 541,794 Note. Sample sizes less than 10 are suppressed to maintain child confidentiality.

Financial and Services Accountability Management System (FASAMS)3. Behavioral

health service data from October 2018 through December 2018 was extracted for the sample.

Behavioral health services were limited to those provided during out-of-home services. The

evaluation team compared SAMHIS and FASAMS service data to remove duplicate services

(some children had service encounters with the same date of service and same procedure code in

both data systems). Duplicate services were excluded from the SAMHIS data. There were 2,201

encounters from FASAMS for 148 children. Table 4 contains the services from FASAMS.

3 The SAMHIS platform was ‘closed’ and the FASAMS system ‘opened’ on October 1, 2018. The date of service on some services in FASAMS was prior to October 1, 2018. Thus, the date ranges do not necessarily reflect the date of service. There were also some encounters reported in both SAMHIS and FASAMS; duplicate encounters were excluded.

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Similar to SAMHIS, the most frequently provided service was in-home and on-site services

overlay (n=942). However, expenditures were highest for crisis stabilization services ($75,898).

Table 4. Behavioral Health Services Paid by DCF Substance Abuse and Mental Health Funds, October 2018-December 2018

Cost Center Description Number of children Number of encounters Total Expenditures Assessment 81 130 4,841 Case Management <10 39 1,467 Crisis Stabilization 31 260 75,898 Crisis Support/Emergency <10 10 283 In-Home and On-Site Services Overlay 26 942 47,342 Intervention 21 212 8,656 Medical <10 11 1,055 Outpatient-Individual 10 147 6,853 Residential Level 2 <10 164 25,504 Substance Abuse Detoxification <10 22 4,839 MH Comprehensive-Individual <10 264 10,276 Total 148 2,201 187,014 Note. Sample sizes less than 10 are suppressed to maintain child confidentiality.

Medicaid recipient, claims, and encounter data. Florida Medicaid claims and encounter

data were extracted for all children in the sample.4 For inpatient and outpatient services,

behavioral health services were defined based on the primary ICD-10 diagnosis code for the

claim/encounter (F00-F99). For pharmacy services, behavioral health services were identified

based on the therapeutic class for the medication (AHFS therapeutic class codes 281 and 282).

To provide a consistent method for reporting data, each service was assigned a cost

center comparable to the SAMHIS and FASAMS data. Using SAMHIS data, we determined the

most frequent cost center assigned to each procedure code. This cost center was assigned to each

4 Some services may be reported in both SAMHIS/FASAMS and Medicaid data. We excluded all encounters from SAMHIS/FASAMS with Medicaid listed as the funder of services. Thus, the degree of overlap should be minimal.

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Medicaid-funded service based on the procedure code reported on the claim or encounter.5

Table 5 contains a summary of the data from the Medicaid files. Assessment services were

received by 3,573 children.6 The most frequently provided services and highest expenditure

services were in-home and on-site services (76,194 service encounters) and residential services

(53,618 service encounters7).

Table 5. Behavioral Health Services Paid by Medicaid Program, January 2016-December 2018 Cost Center Description Number of children Number of claims/encounters Total Expenditures

Assessment 3,573 12,796 2,040,700 Case Management 804 22,207 1,273,995 Crisis Stabilization 193 392 36,898 Day-Night Services/Skills Training 35 1,539 217,890 In-Home/ On-Site Services Overlay 2,224 76,194 8,247,708 Inpatient 401 2,839 2,816,953 Intervention 240 4,529 196,660 Medical 1,402 7,811 380,938 Outpatient-Individual 2,341 40,732 3,292,158 Residential Level 2 238 53,618 13,070,903 Outpatient-Group 234 23,660 861,340 MH Comprehensive-Individual 42 112 13,550 Medicaid Pharmacy 908 13,345 477,337 Other 1,272 21,252 1,115,214 Total 4,064 281,026 34,042,244

5 While providing a simple method for comparison across data sources, it is important to note that the assignment of cost centers to Medicaid services is an approximation. In SAMHIS, a procedure code often maps to multiple cost centers. The use of the modal cost center will inevitably lead to some services in the Medicaid data being assigned to an incorrect cost center. 6 The average number of assessments per child, 3.58, may seem large. Thus, we took a closer look at the claims/encounters; 89% had a procedure code of H0031: mental health assessment –non-physician and 8% had a procedure code of H2000: comprehensive multidisciplinary evaluation. The remaining 3% had procedure codes denoting a psychiatric diagnostic evaluation or alcohol/drug assessment. 7 A Medicaid claim or encounter may or may not represent a single service. While an outpatient claim tends to represent a single service, an inpatient or residential claim or encounter typically represents services provided over a period a time (e.g., a day, week, or month). There may also be one or multiple claims per inpatient or residential stay. As a result, the number of claims or encounters does not represent the number of inpatient or residential stays or the number of service days, and the data in Table 5 cannot be used to compute the cost per unit of service.

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Note. Residential Level 2 includes Statewide Inpatient Psychiatric Program, Specialized Therapeutic Group Home, and Specialized Therapeutic Foster Care services. The Other category includes services that did not quite fit any of the established cost centers (e.g., transportation, DME, laboratory services). Service encounters represent the number of claims/encounters for the service in the data. In some cases (e.g., residential), there may be numerous encounters for a single residential treatment stay.

All Funding Sources. Table 6 contains a summary of the data from all funding sources.

Assessment services were received by 3,635 children. The most frequently provided services

and highest expenditure services were in-home and on-site services (80,537 service encounters)

and residential services (54,221 service encounters). The two cost centers accounted for over

$21.8 million of the $38.9 million in total expenditures.

Table 6. Behavioral Health Services Paid by All Funding Sources, January 2016-December 2018

Cost Center Description Number of children Number of encounters Total Expenditures

Assessment 3,635 13,834 2,177,459

Case Management 827 22,835 1,297,416

Crisis Stabilization 230 848 170,254

Crisis Support/Emergency 33 80 2,285

Day-Night Services/Skills Training 35 1,539 217,890

In-Home/ On-Site Services Overlay 2,292 80,537 8,569,757

Inpatient 401 2,846 2,820,099

Intensive Case Management <10 <10 54

Intervention 311 5,843 245,865

Medical 1,402 7,841 383,794

Outpatient-Individual 2,405 43,146 4,084,087

Prevention 59 138 30,955

Residential Level 1 <10 12 2,750

Residential Level 2 245 54,221 13,285,109

Residential Level 3 20 79 168,296

Residential Level 4 <10 279 13,460

Respite Services 164 535 1,932,351

Substance Abuse Detoxification 34 221 48,608

Supported Housing <10 16 753

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TASC <10 41 1,383

Incidental Expenses 56 164 142,269

Aftercare/Follow-up <10 68 3,267

Behavioral Health Overlay Services' <10 <10 3,398

Outpatient-Group 235 23,662 861,397

Room & Board Level 2 <10 147 16,309

Intervention-Group 10 309 6,336

MH Comprehensive-Individual 113 1,131 498,476

SA Recovery Support-Individual <10 <10 211

SA Recovery Support-Group <10 <10 45

Medicaid Pharmacy 909 13,346 477,541

Other 1,337 21,628 1,433,287

Total 295,364 38,895,158

Deriving the final sample. There were 5,022 out-of-home care episodes for 4,855

children in the initial sample. From this initial sample, the final sample included all children that

received at least one behavioral health service. All services identified in Our Kids, SAMHIS,

FASAMS, and Medicaid data were used to identify children who received at least one behavioral

health service in 2016, 2017, and 2018 with some exceptions.8

There are several types of services that may or may not have a behavioral health

component. Thus, after consultation with DCF staff, it was decided to exclude some services

when identifying the final sample. Thus, a child was excluded from the sample if they only

received the following services:

1. Alternative services paid by Our Kids (e.g., Motivational Edge, dance therapy, martial

arts, tutoring),

8 While the following services were excluded when considering whether to include the child in the sample, all services will be included when reporting the services received by children in the sample. For example, tutoring services may not prove the presence of a behavioral condition, but may be very important for children that have a behavioral health condition.

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2. Cost centers that are not treatment related (respite services, supported housing, supported

employment, incidental expenses),

3. Medicaid claims and encounters with a primary ICD-10 codes denoting a behavioral

health condition, but procedure codes denoting services that may not have a behavioral

health component (e.g., surgery, radiology, laboratory services, transportation, supplies)9,

4. Services with primary ICD-10 codes denoting mental retardation (F70-F79) or disorders

of physiological development (F80-F89), and

5. Pharmacy services (some behavioral health medications are also used for physical health

conditions).

After excluding these services, the final sample contained 3,257 children that received at least

one mental health or substance abuse treatment service while receiving out-of-home child

welfare services. All services were included in the report, including those excluded above, for

children in the final sample.

Analysis. The descriptive analysis examined how services and expenditures vary with

child characteristics, diagnoses, time in child welfare, and placements. In general, results were

reported separately for Miami-Dade County and Monroe County, although in some cases results

were aggregated in Monroe County due to the smaller sample size.

One challenge with interpretation of simple descriptive findings is that child

characteristics, diagnoses, time in child welfare, and placements are often highly correlated.

Thus, it can be challenging to conclude that any single characteristic is associated with

behavioral health expenditures because that characteristic may also be correlated with other

9 While some of these services will have a behavioral health component, a review of services found numerous lab tests for comprehensive metabolic panels and radiology claims for EKGs that were less likely to have a behavioral health component.

22


factors associated with expenditures. The research team estimated a simple regression where

behavioral health expenditures were regressed on child characteristics, diagnoses, time in child

welfare, and placements. The results provided a clearer picture of which characteristics are most

strongly associated with expenditures.

Case Record Reviews

Utilizing Florida Safe Families Network (FSFN) data, community-based care lead agency

data, DCF Substance Abuse and Mental Health funding data (Substance Abuse and Mental

Health Information System [SAMHIS] and Financial and Services Accountability Management

System [FASAMS]), and Medicaid data, a sample of 3,257 children were identified in Miami-

Dade or Monroe counties who were receiving out-of-home child welfare services in calendar

years 2016, 2017, and 2018 and received at least one mental health or substance abuse treatment

service during this time (see Southern Region Gap Analysis Utilization Pattern and Service

Usage Report; Johnson et al., 2019). From this sample, a sub-sample of 165 children was

randomly selected for case file review. The sample was stratified by age into three groups: birth

to age five, ages 6-12, and age 13 and older.10

To document and assess the behavioral health service needs of the sample of children in

out-of-home foster care placement, the study team developed a case record review protocol that

included child demographic information, maltreatment type(s), mental health diagnoses, child

welfare and mental health assessments, child mental health needs, services, evidence of service

receipt, and case planning and communication to meet the child’s identified mental health needs.

The study team used the record review protocol to document the relevant information contained

10 The age groups and sample sizes were determined by DCF. The goal was to have sufficient sample sizes to have 80% power to detect medium effect size differences between the age groups. The software package G*Power indicates 81% power to detect medium effect size differences between the three groups suggesting that the sample sizes were sufficient.

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in FSFN and ASK, the cloud-based file record system managed by Citrus Health Network. The

team reviewed all available records including case manager chronological notes, Family

Functioning Assessments, legal documents, staffing notes, supervisory reviews, the child’s

medical and mental health conditions and disability sections of FSFN, and mental health

assessments and reports from providers.

Data collected through the record review protocol were entered into a spreadsheet and

analyzed using SPSS statistical software to explore patterns in children’s behavioral health needs

and service recommendations. Descriptive statistics were calculated by age group for all study

variables. Pearson’s chi-square was used to analyze differences by age group for categorical

variables, such as distribution of specific maltreatments, diagnoses, behavioral health

assessments, and service recommendations. Analysis of variance (ANOVA) was used to analyze

differences by age group for quantitative variables, including the number of maltreatments,

diagnoses, and service recommendations a child received.

Analysis also examined the level of consistency between children’s service needs as

determined by the behavioral health care provider assessments and child welfare assessments

documented in FSFN and ASK. Pearson’s correlation analysis was used to examine associations

among child welfare mental and behavioral health needs assessment ratings, number of

maltreatment allegations, number of diagnoses a child received, and number of service

recommendations that were made. A contingency table was also produced to further examine

relationships among child welfare and behavioral health provider assessments of need.

Document Review

The study team obtained copies of Sunshine Health’s provider manual, DCF’s

operational procedures, and the full case management services contracts between the CBC Lead

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Agency (CFCN) and the Case Management Agencies for the Southern Region. Sunshine Health

is the Medicaid managed care organization that operates Florida’s Child Welfare Specialty Plan

(CWSP). Although the CWSP is not the only Managed Medical Assistance (MMA) plan

available to children entering out-of-home care, we were unable to obtain copies of all the MMA

plans for the Southern Region. Furthermore, the CWSP is the only plan that is explicitly

contracted to serve the child welfare population, and Medicaid data indicate that the majority of

children in out-of-home care do ultimately enroll in the CSWP. For these reasons, our policy

analysis focused on the Sunshine CWSP. The Sunshine Health Provider Manual includes a

small section detailing policies and procedures specific to the CWSP.

DCF’s policies and procedures pertaining to children’s behavioral health assessment and

care are laid out in CF Operating Procedure 170-10: Providing Services and Support for

Children in Care and for Caregivers. Both sets of policies were reviewed and analyzed by a

member of the study team to identify specific requirements established for behavioral health

providers and child welfare staff. Review of the case management contracts focused on

identifying and assessing what policies and procedures were established between CFCN and the

case management agencies regarding the provision and coordination of care for children who

require behavioral health services.

Interviews

The study team completed 16 interviews with clinical leadership from children’s

behavioral health care service providers and the managed care organization in the Southern

Region. Interviews were typically done individually, but the option was given to include a

second interviewee to provide input. To identify potential participants, the study team requested

contact information from the CBC Lead Agency and case management agencies for providers

25


they use most frequently, and reviewed providers listed in the Sunshine Health Child Welfare

Specialty Plan directory. This resulted in a list of approximately 65 provider agencies.

Potential interviewees were initially contacted via email by the research team to explain

the purpose of the interview. Scheduling was then done by phone. Of the 65 providers, 19

responded that they did not serve children, and were excluded from study. Thirty providers

could not be reached or did not respond to the request to schedule an interview. For those who

agreed to participate, the interview questions and informed consent documents were shared prior

to the actual telephone interview.

Interviewees were asked to share information about the procedures used to assess the

behavioral health needs of children in licensed foster care, their perception of the service needs

of children in the region, their perception of the level of care coordination, and their perception

of the service capacity and accessibility compared to the needs of the children in care. The

interviews were audio-recorded with the permission of participants. Recordings were

professionally transcribed and then coded by a member of the study team using a grounded

theory approach to identify emergent themes.

Focus Groups

A set of focus groups was conducted with case managers from each of the contracted

case management agencies serving the Southern Region. The purpose of the focus groups was to

explore the role of case managers in facilitating and coordinating behavioral health care services

for children in licensed foster care. Four focus groups were convened, one with each case

management agency. A semi-structured interview guide was used to facilitate the focus group

sessions. Topics discussed during the focus groups included the role of case managers in

assessing children’s behavioral health needs and coordinating care for children in licensed care,

26


specific policies and procedures that pertain to these aspects of their job, perceptions of the

behavioral health service array, and any challenges or barriers to meeting the behavioral health

care needs of children in licensed care. Focus groups ranged in size from three to seven

participants, with a total of 20 participants across the four groups. The focus groups were audio-

recorded and transcribed. Transcripts were coded to identify emergent themes and concepts

from the data.

Surveys

Surveys for behavioral health providers and case management staff were created in

Qualtrics, a web-based survey program. Two distinct surveys were developed; one for

children’s behavioral health provider agencies, and one for case management agencies. The

surveys were designed to gather data related to the availability and accessibility of behavioral

health services for children in licensed foster care. Potential respondents were sent an email with

a link to participate in the survey. To maximize participation, a multi-wave mailing strategy was

used, whereby non-responders were sent a reminder email every 10 to 15 days. Ten weeks after

the initial survey invitation went out, the study team also attempted to contact non-responding

agencies by phone.

Provider survey. The provider survey was designed to identify the array of behavioral

health services available to foster care children in the Southern Region and service capacity of

providers. Specifically, the survey solicited the following information: specific types of

behavioral health services provided to children in foster care (including names of specific

practices/models and evidence-based practices), any specific eligibility criteria for the service,

number of staff trained/certified to provide each specific service/practice, number of children

each trained staff can carry on their caseload, how the service is provided (e.g. in the office, in

27


the client’s home, etc.), what role the provider plays in service coordination, the typical service

duration and dosage, the number of children served in the past year, and what the typical wait

time is to initiate services.

A total of 51 distinct behavioral health provider agencies were identified and targeted for

administration of the survey. Agencies were identified through several methods. First, the study

team asked the current CBC Lead Agency (CFCN) to identify major providers with whom they

work. Second, the Sunshine Plan Provider Directory was consulted for additional agencies.

Third, Medicaid claims data was used to identify the most frequently used providers. For each

identified agency, one or two administrative level employees, such as Directors or Operations

Managers, were identified and asked to respond to the survey; this resulted in distribution of the

survey to 96 individuals, with the instruction that only one individual per agency needed to

complete the survey. Of these, 15 agencies reported that they do not serve the target population

(children in licensed foster care) and were subsequently removed from the distribution list. This

left a total of 36 eligible agencies, of which 20 agencies (55.6%) completed the survey. Survey

responses were exported to SPSS, a statistical software program, and descriptive analyses were

performed. After the survey results were finalized, additional internet research was conducted to

gather further information on service availability for providers who did not complete the survey.

Case management survey. The case manager survey was designed to assess case

manager awareness and perceptions regarding the availability of necessary behavioral health

services for the children they service. This survey solicited the following information in relation

to distinct types of behavioral health needs: the extent to which services are available to meet the

need, the extent to which services are accessible, the extent to which services are effective, and

28


the adequacy of the current service capacity. The survey also included questions about perceived

gaps or service needs, and questions about the respondent’s role in care coordination.

The survey was distributed to case management agency staff by the agency directors.

Distribution was targeted to all case management staff, including direct case managers,

supervisors, program managers, and other support staff who assist with the coordination of care.

A total of 59 responses were received. Of these, 21 respondents (36%) only answered initial

background questions (e.g. agency, position, number of years worked) but did not complete the

questions pertaining to the service array, and therefore were eliminated from the analysis. This

left 38 valid responses, which were included in the analysis. The survey responses were

exported to SPSS and descriptive analyses were performed.

Results

Study findings are organized in four sections. First, we present findings related to the

processes in place to identify and assess the behavioral health needs of children in licensed care

and coordinate services to address those needs. The next section details findings pertaining to

children’s documented behavioral health needs, as identified through case record reviews, as

well as stakeholder perceptions of unmet needs. The third section describes the behavioral

health service array and service capacity for children in licensed care. The final section provides

an analysis of behavioral health service utilization and service patterns for children in licensed

care.

Processes and Procedures for Identifying Children’s Behavioral Health Needs

This section provides results for the processes among child welfare and behavioral health

providers for determining the behavioral health needs of children in licensed care. Findings are

organized around three domains: assessment processes, care coordination, and documentation.

29


Data relating to policies and procedures for identifying children’s behavioral health needs were

derived from behavioral health provider interviews, case manager focus groups, case file

reviews, and review of DCF, CBC, and managed care policies.

Assessment processes. Policies for the assessment of children’s behavioral health needs

are established by the MCO (Sunshine Health) and DCF. The Sunshine Health Provider Manual

specifies requirements of the Child Welfare Specialty Plan (CWSP) providers for behavioral

health assessments of children in licensed care. In particular, providers are expected to prioritize

the scheduling of these appointments within 72 hours of the request, and provide assessment

results to DCF or the CBC within two business days. There is no further specification provided

in the manual as to the type(s) of behavioral health assessment to be performed or procedures for

completing the behavioral health assessment.

DCF policy lays out several requirements regarding behavioral health assessment and

service provision for children in licensed care. The policy specifies that a Comprehensive

Behavioral Health Assessment (CBHA) must be completed for all children entering out-of-home

care, and the referral for the CBHA must be made within seven business days of the child’s

removal. Furthermore, the policy states that the assigned caseworker must document the

assessment of current and historical child functioning in the Family Functioning Assessment

(FFA), including screening for emotional health needs, trauma, behavior issues, and any needs

identified through the CBHA. There are no specific screening or assessment tools identified in

the operating procedures for caseworkers to use, other than the FFA, in assessing children’s

behavioral health needs. In addition, the family case plan is expected to include a description of

the child’s identified behavioral health needs and the services to be provided to address those

needs. The assigned caseworker is required to document the child’s behavioral health condition

30


in the Medical/Mental Health section of FSFN, and upload the completed CBHA and any other

professional evaluations that have been received. If the child has been clinically diagnosed with

a specific disability, it should be recorded in the FSFN Disability tab, and if the diagnosis

changes or is determined by a clinical professional to no longer exist, it should be end-dated in

FSFN.

Findings from behavioral health provider interviews, behavioral health provider surveys,

case file reviews, and case manager focus groups contributed to a descriptive analysis of what

assessment tools were currently in use. Behavioral health providers identified several

standardized assessment tools that are used. A complete list of the tools that were mentioned is

provided in Appendix B. The tools used varied by provider. Respondents also stressed that

these were commonly used examples, but that there was an array of assessment tools based on

symptoms a child presents with that could be used for a more in-depth look. Case file reviews

found that assessments commonly completed as part of the CBHA included the Child and

Adolescent Needs and Strengths (CANS), the Child Behavior Checklist (CBCL), the Trauma

Symptoms Checklist (TSC), and the Ages and Stages Questionnaire (ASQ). Treatment planning

traditionally followed the assessment process.

Regarding assessment processes on the case management side, respondents across the

case manager focus groups reported that initial provider assessments (e.g. the CBHA) as well as

observations from home visits with children were the main sources for assessing children’s

needs. They were particularly dependent upon the CBHA, as most respondents expressed that

they did not receive training on children’s behavioral health issues and were not qualified to

assess those needs.

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All behavioral health provider interview respondents indicated that the assessment tools

used were adequate, with a few qualifications. One respondent discussed how the assessment

process could at times be so in-depth or lengthy, depending on all that is involved, that the

provider runs the risk of losing the child’s attention or not building the initial level of rapport that

is helpful to begin services in the midst of trauma. This respondent felt that tools focusing more

on the current traumatic event were most helpful. In addition, respondents mentioned that

getting an adequate history for the child during an assessment was challenging at times if the

case manager brought them in and they had been placed in foster care, such that contact with the

biological parent or previous foster care placements might not be immediate or possible.

Another respondent wished for better assessment tools for Autism Spectrum Disorders.

In contrast to provider perspectives, case manager focus group participants expressed a

variety of concerns pertaining to the behavioral health assessment process. One concern was

with the timeliness of the CBHA; case managers reported that sometimes there were delays or

wait lists to get those assessments completed. This was confirmed by respondents on the

provider survey, who reported wait times of up to 21 days for the CBHA. These wait times are

in conflict with the MCO policy that assessments be conducted within 72 hours of the referral.

Another concern expressed by case managers was with regard to the quality of the assessments.

Many case managers were skeptical about the ability of assessors to adequately and accurately

assess a child’s needs given the minimal amount of time they spend with the children. Some also

expressed the perception that CBHA reports were “cookie cutter” and assessors were in the habit

of “cutting and pasting” their reports.

Respondents further felt that the recommendations provided in the CBHA were often

generic. Case managers claimed that recommended services usually fell into two categories of

32


clinical services: talk therapy/counseling and psychiatry. Respondents made it clear that they

were not discounting the benefits of those services, but felt concerned that there was too much of

a “one size fits all” approach with regard to service recommendations. Additionally, at times

they observed what they perceived to be the misdiagnosing of children and/or over-reliance on

medications to handle, for example, ADHD (noted as a common diagnosis for behavioral

problems); the sentiment expressed was that sometimes underlying issues and mitigating factors

were not addressed but simply placated to work within the timelines of cases. Across sites, there

were critiques of “best practices” that confound the challenges these front-line workers

experienced daily. Differing perspectives of what is best for a client created power dynamics

and distrust from case workers on the reliability and effectiveness of assessments that informed

referrals to providers. One respondent fleshed this out as follows:

I had a two-year-old get referred for speech therapy, occupational therapy, emotional individual therapy, every service and it was only an evaluation completed for two hours. How could you gather all of that just off a two-hour session? When I see her, she’s talking fine, she’s walking, she’s running, she’s jumping [and] climbing on my neck. I don't see why she needs these services. Neither does the PCP [primary care provider]. But because you have this assessment that recommends these services, now I have to go to every service provider, just for them to say, ‘oh no, she doesn’t need it.’ And then you have those service providers who’s like, well Medicaid’s paying, I’m going to get all the money I can, so she’s going to do the services.

As this narrative illustrates, there were considerable concerns about the validity of the assessments

provided and the possibility of misdiagnosis when assessments were rushed or conducted with

incomplete information.

Care coordination. The Sunshine Health Provider Manual specifies requirements for the

coordination of care between the CWSP providers and the child welfare system and training for

providers. The manual notes that Sunshine Health offers training for providers on the unique

needs of child welfare involved children, but does not specify whether participation in such

33


training is a requirement for CWSP providers. The manual also indicates that Sunshine Health

funds CBC coordinators to support communication and information sharing between the

Medicaid and child welfare systems. With regard to the coordination of care with DCF and CBC

Lead Agencies, the manual states that providers are required to assist in scheduling

appointments, provide periodic written updates on the child’s treatment status as requested, and

participate in training provided by Sunshine Health about coordination with the child welfare

system.

Review of the case management agency contracts concluded that there were contractually

established policies and procedures between the CBC (CFCN) and the case management

agencies regarding the coordination of care for children with behavioral health needs. There are

two sections of the full case management service contracts that detail most of the policies and

procedures relating to how case management services should be provided. These are Attachment

I: Scope of Work and Exhibit A: Service Tasks. The Scope of Work in Attachment I detailed

program goals related to safety, permanency, and well-being; however, the specified goals

focused more on permanency/placement, adoption, and education goals. The Service Tasks

listed in Exhibit A provided a more detailed account of the required activities that related to

behavioral health services.

The Comprehensive Behavioral Health Assessment (CBHA) was mentioned in the

Service Tasks as the assessment that should guide case planning and service referrals. The

contracts stated that the case managers were to “utilize the results and recommendations of the

CBHA in developing the dependency case plan, including addressing the child’s and family’s

mental health needs. If the case plan is developed prior to the completion of the CBHA, the use

of the assessment in developing, accessing, and referring for behavioral health services will be

34


documented in the child’s case file.” The contracts also stated that children should be connected

to the recommended services from the CBHA no later than 30 days from the assessment.

The contractual agreements identified the case managers as the primary coordinators of

services: “The case manager will coordinate and track services for all family members and obtain

reports from all service providers for quality decision-making and compliance.” The contracts

also required participation in multidisciplinary and/or permanency planning staffings and

required that the appropriate CFCN staff be notified to participate in those staffings. In addition,

the contracts stated that the case management agencies must comply with the Department of

Children and Families Operating Procedures, which include a specific set of operating

procedures for the integration of mental health, substance abuse, and developmental disabilities

services for children in out-of-home care.

Behavioral health providers offered input on their role in and perceptions of care

coordination through the provider survey and interviews. Most survey respondents indicated that

providers at their agency developed individualized treatment plans for the children they served

(86.7%) and that treatment plans were developed jointly with the child and their caregiver(s)

(80%). Examples of how clients were engaged in treatment planning included identifying their

own goals and strengths, writing treatment plans using the client’s own words and language they

understand, and having clients review and sign their treatment plan. Slightly fewer respondents,

but still a majority, reported that the child’s case manager was also involved with treatment

planning. Respondents generally stated that they worked closely with case managers to

coordinate services and ensure children’s needs were met and provided reports to the case

management agency and court on the child’s treatment progress. For the most part, they reported

that treatment plans were reviewed and updated every six months; 80 percent reported that this

35


always occurred, 10.5 percent reported that this usually occurred, and only 5.3 percent reported

that it rarely or never occurred.

Behavioral health providers’ perceptions of the level of care coordination in the region

varied greatly. Several interview respondents expressed the perception that there was a very

high level of coordination. These individuals described having close relationships with

community partners and good communication across agencies, including with DCF, the CBC,

and the case management agencies. One provider also identified care coordination as a priority

of the managing entity, and reported that they convene monthly meetings of the network

providers to ensure that each agency is aware of one another, what each offers, and how they can

work together to ensure children’s needs are met.

Other behavioral health provider respondents were less optimistic about the degree of

care coordination that was occurring, although they acknowledged and emphasized the

importance of coordination. A common consensus among these respondents was that there was

room for improvement. One respondent noted that there was a lot of great effort around

coordination, but these efforts were not necessarily as effective as they needed to be. Another

respondent expressed that while some providers were trying, it seemed that not all providers

were “fully cooperative” when it came to cross-system coordination and collaboration. Other

descriptions of the service system and coordination efforts included “fragmented,” and

“unorganized,” with one respondent expressing concern that “kids fall through the cracks,”

particularly when they are transferred from one provider to another.

A need for greater communication and information sharing was one of the most

commonly identified challenges by behavioral health providers. It was reported that providers

were not always aware of one another or what other services a particular child was receiving, and

36


that providers did not always receive pertinent information about changes in a case (e.g. a child’s

placement change or reunification). As one respondent characterized this disjunction: “It seems

like sometimes, though, the right hand doesn’t know what the left hand is doing.” One

suggestion provided was for the incorporation of multi-disciplinary staffings at regular intervals

to ensure that all providers working with a particular child and/or family were aware of the

various services being provided and the current status of the case plan.

It was further noted by behavioral health providers that coordination with case

management varies and was often dependent on the particular case manager assigned to a case.

High staff turnover and high caseloads among case management agencies were perceived to be

the primary factors contributing to poor coordination on the case management side. The impact

of these factors was that case managers may not know the children on their caseload very well,

and as a result may not be knowledgeable enough about the children’s needs to identify the most

appropriate services for them. Furthermore, high caseloads impact the amount of time that case

managers have available to spend on coordinating services for their clients.

Child welfare case managers contributed additional insights on care coordination. Case

management survey respondents generally described their role in care coordination as providing

service referrals, following up on referrals to ensure that children have been linked to services,

and ensuring the overall safety and well-being of the children under their care. Some

respondents also identified monitoring children’s outcomes and quality assurance as part of their

role. Focus group participants offered similar descriptions. Perhaps the largest portion of their

job, case managers reported that they are responsible for coordinating care through referrals to

clinical providers and linking clients to community resources or services that fall outside of the

formal scope of the job. After they received the CBHA results, they sent referrals out to

37


providers who deliver the recommended resources. Case managers reported that the CBHA

typically did not identify or provide recommendations about specific providers or treatment

modalities to meet the child’s particular needs, which meant that case managers were left with

the task of identifying appropriate providers. At each of the case management agencies, they had

an established network of preferred providers with whom they worked, and case managers

expressed that there were personnel at their agencies who provided assistance with identifying

service providers.

Notably, neither the case managers nor the behavioral health provider respondents

mentioned the care coordinators provided by Sunshine. Although Sunshine’s policies indicate

that these care coordinators participate in multi-disciplinary team meetings to assist in providing

clinical expertise and identify appropriate services for children’s identified needs, the extent to

which this was integrated into routine practice was unclear. Frontline workers did not appear to

be aware of the availability or role of Sunshine care coordinators, giving the impression that their

contribution to care coordination was limited and far less hands-on than the role child welfare

case managers play in coordinating care.

Case manager focus group participants expressed that their role in care coordination did

not end with the service referrals. Subsequently, they were responsible for ensuring that

appointments were made and following up to ensure the child actually received the services.

Additionally, they requested regular updates from providers to monitor the child’s progress,

reviewed progress reports, and routinely assessed whether the services were meeting the child’s

needs or whether they needed to reassess the treatment plan. One challenge many case managers

experienced was limited or complete lack of communication from providers. In some instances,

it was reported that providers failed to inform case managers when children missed appointments

38


or even that a child had been discharged from services. Delays in receiving progress reports

from providers, the need to make multiple requests to receive reports, and poor-quality reports,

were common challenges.

The other main challenge case managers described in relation to coordinating care was a

lack of cooperation from foster parents. Across the focus groups, respondents expressed

frustration that many foster parents did not view it as their responsibility to take children to their

appointments. Numerous examples were provided of how case managers had to renegotiate their

schedules to transport clients to court, school, and a plethora of various appointments because

foster parents refused to do so. When asked how common this was, respondents in one focus

group expressed that it was the majority of foster parents. Not only does this create additional

burden for already over-burdened case managers, but lack of engagement from foster parents

may also hinder a child’s treatment progress if caregivers do not actively participate in the

child’s treatment or communicate with the child’s provider about how the child is doing at home.

Documentation. This final area of inquiry has to do with the requirements for

documentation set forth by policy, and adherence to stated guidelines in terms of what is entered

into FSFN. Data to answer this question was gathered via contract/policy review and case file

review. An important aspect of the contracts reviewed were requirements to document all

mandatory activities. The Child Resource Record (CRR), the CFCN client case file, and the

Florida Safe Families Network (FSFN) were indicated as areas where the case management

agencies should document information that correspond with the required activities. The

contracts stated that the CRR should be initially developed and monitored by the case manager,

however, the CRR should be maintained by the caregiver of the home where the child resides

and should be provided to the physician at each physical health or behavioral health

39


appointment. The CFCN client file and the FSFN data system should contain case notes,

treatment plans, and progress notes regarding the physical health and behavioral health services

that each child received. Furthermore, DCF policy dictates that the CBHA should be uploaded

to FSFN, and the results should be incorporated in the FFA.

Accordingly, as part of the case file reviews completed for the study, FSFN and ASK

were reviewed for documentation of completed mental health assessments, particularly the

CBHA, which is required for every child who enters out-of-home care. Most children (84.8%,

n=140) had a CBHA documented in their file, however, these were not uploaded to FSFN as

required per DCF policy, but were located in the ASK case management data system. Review of

these assessments found that they were typically very detailed and comprehensive, however, the

recommendations they provided were often for generic service categories (e.g. individual

counseling) as opposed to recommendations for specific treatment modalities or evidence-based

treatments in accordance with the child’s particular needs. Furthermore, review of the FFAs

contained in the case files found that these were not a reliable source to identify a child’s

behavioral health service needs. While some FFAs were comprehensive with detailed narrative

that reflected the current emotional and behavioral functioning and needs as outlined in the

mental health assessments and other case documents, this was not typical. Thus, while the

majority of case files contained the required FFAs, the assessments completed did not

necessarily address the child’s functioning or behavioral health needs and often did not

incorporate findings from the CBHA as specified in DCF policy.

Mental and Behavioral Health Needs of Children in Licensed Care

This section examines the mental and behavioral health needs, and unmet needs, of

children receiving out-of-home foster care services in the Southern Region. Analysis of child

40


needs draws largely on case record reviews completed on a sample of 165 children in licensed

care between 2016 and 2018. Findings from the case record review analysis were then used to

produce estimates of child needs for the entire Southern Region child welfare population.

Finally, perspectives of behavioral health providers and case management staff on the mental

health needs and unmet needs of children in licensed care, solicited through interviews, focus

groups, and surveys, are incorporated and provide additional context.

Child characteristics. Demographic and case characteristics of the 165 children

randomly selected for detailed record review are summarized in Table 7. There were 55 children

in each of the three pre-determined age groups. Ninety-seven percent of the children (n = 160)

lived in Miami-Dade County. There were slightly more females than males in the sample, and a

slight majority of children were identified as Black/African American and came from single

parent homes. Domestic violence, substance abuse, and inadequate supervision were the most

common forms of maltreatment identified in the case files. Many children experienced more

than one type of maltreatment. The number of maltreatment allegations per child ranged from

one to five, M = 1.68 (SD = 0.87). There were 17 children in the sample for whom maltreatment

allegations could not be found in the case file.

Approximately 31.5% (n=52) were placed in a licensed foster home and 47% (n=77)

were living with a relative or non-relative (e.g. family friend, godparent) caregiver. The

remaining children (21.2%) were either in a group home, shelter, court-ordered supervision,

independent living, pre-adoptive placement, or a higher level of care placement, which included

medical foster homes, specialized therapeutic foster care (STFC), specialized therapeutic group

homes (STGH), and the Statewide Inpatient Psychiatric Program (SIPP). Most of the children in

the sample (72.1%) entered child welfare during the period under review (2016-2018). The

41


remaining children in the sample entered care between 2011-2015, with the exception of one

child who entered care in 2003 and one in 2006.

Table 7. Child Characteristics by Age Group

Child Characteristics Ages 0-5 (N = 55)

Ages 6-12 (N = 55)

Ages 13-17 (N = 55)

Total (N=165)

n % n % n % n % Gender Male 23 41.8 25 45.5 25 45.5 73 44.2 Female 32 58.2 30 54.5 30 54.5 92 55.8 Race/ethnicity Black/African American 32 58.2 27 49.1 29 52.7 88 53.3 Hispanic/Latino 17 30.9 22 40.0 20 36.4 59 35.8 White (non-Hispanic) 2 3.6 3 5.5 3 5.5 8 4.8 Other/multi-racial 4 7.3 3 5.5 3 5.5 10 6.1 Family Structure

Married couple 7 12.7 6 10.9 10 18.2 23 13.9 Unmarried couple 16 29.1 11 20.0 9 16.4 36 21.8 Single female 24 43.6 31 56.4 31 56.4 86 52.1 Single male 2 3.6 3 5.5 2 3.6 7 4.2 Unable to determine 6 10.9 4 7.3 3 5.5 13 7.9

Placement*** Licensed foster care 29 52.7 9 16.4 14 25.5 52 31.5 Relative/non-relative care 21 38.2 38 69.1 21 38.2 77 46.7 Other placement⸙ 5 9.1 8 14.5 19 34.5 35 21.2 Maltreatment† Family/household violence 19 34.5 12 21.8 10 18.2 41 24.8 Substance misuse* 20 36.4 14 25.5 8 14.5 42 25.5 Inadequate supervision 11 20.0 16 29.1 8 14.5 35 21.2 Physical abuse/injury 10 18.2 9 16.4 14 25.5 33 20.0 Absence of care⸹ 5 9.1 8 14.5 10 18.2 23 13.9 Neglect 9 16.4 7 12.7 6 10.9 22 13.3 Sexual abuse* 1 1.8 6 10.9 12 21.8 19 11.5 Environmental hazard 5 9.1 8 14.5 3 5.5 16 9.7 Other maltreatment⸕ 3 5.5 7 12.7 6 10.9 16 9.7

***Chi-square significant at the p < .001 level. *Chi-square significant at the p < .05 level. ⸙Other placement types included group home, STFC/STGH, SIPP, shelter, hospital, medical foster home, independent living, court-ordered supervision, and pre-adoptive home. †Percentages add up to more than 100, since children may experience more than one type of maltreatment. ⸹Absence of care includes abandonment, loss of caregiver due to death or disability, and incarcerated caregiver. ⸕Other maltreatment includes threatened harm, psychological abuse/mental injury, and failure to protect.

Further analysis examined whether sample characteristics varied by age. There were no

differences in the distribution of gender or race/ethnicity among the age groups. The distribution

of placement types differed significantly by age group. Young children (birth to 5 years) were

more frequently placed in licensed foster care compared to children in the middle (ages 6-12)

42


and oldest group (ages 13-17). Children ages 6 to 12 years were more frequently placed in

relative care compared to both younger children (birth to 5), and older children (ages 13-17).

Finally, the children comprising the oldest age group (13-17 years) were more frequently placed

in ‘other’ types of placements compared to the younger and middle age groups. Group homes

were the most frequent type of ‘other’ placement (25.7% of ‘other’ placements), however,

represented a small number (n=9) of the overall placements for the sample.

The number of maltreatment allegations did not differ significantly by age group.

However, there were some differences by age group in the distribution of maltreatment types.

The distribution of parental substance misuse allegations differed significantly between children

ages 0 to 5, who experienced parental substance misuse most frequently, and children ages 13 to

17. The distribution of sexual abuse allegations also differed significantly between children ages

0 to 5, for whom there was only one sexual abuse allegation, and children ages 13 to 17, for

whom there were twelve allegations.

Child mental health assessments. FSFN and ASK were reviewed for each child in the

sample for evidence of mental health assessments that were completed. Table 8 presents data on

the most frequently completed mental health assessments found in the case files. Ninety percent

(n=149) of the children in the sample received some form of mental health assessment as

evidenced by documentation in FSFN or ASK. There were 16 children for whom no behavioral

health assessments were found in the case files. The absence of an assessment in the file is not

necessarily an indication that an assessment did not occur. For those who had an assessment in

their file, the number of assessments completed per child ranged from one to eight. The mean

number of assessments completed per child was 2.4 (SD = 1.8).

43


The mental health assessments most frequently utilized included the Comprehensive

Behavioral Health Assessment (CBHA), Biopsychosocial Evaluation, Psychiatric Evaluation,

and a variety of trauma assessments, such as the Child PTSD Symptom Scale or the Trauma

Symptom Checklist for Children (TSCC). Most children (84.8%, n=140) received a CBHA.

Review of these assessments found that they were typically very detailed and comprehensive.

As part of the CBHA, clinicians often administered additional age and symptom appropriate

emotional, behavioral, and developmental assessments, including the Child Behavior Checklist

(CBCL, ages 6-18) and corresponding Youth Self Report (YSR, ages 11-18), Ages and Stages

Questionnaire (ASQ-3, ages 0-5), Beck Depression Inventory, and the Child and Adolescent

Needs and Strengths (CANS).

Biopsychosocial assessments were found for 20% (n = 33) of the sample, and psychiatric

evaluations were found for 17.6% (n = 29) of the children in the sample. Approximately 9% of

the children (n = 15) had a behavioral assessment related to behavior analysis. Psychological

evaluations were less common, completed for only 6.7% (n = 11) of the children. A small

number of children (n < 5) received psychoeducational, suitability, and psychosexual, sexual

abuse, or human trafficking assessments.

Table 8. Most Frequently Completed Mental/Behavioral Health Assessments by Age Group

Behavioral Health Assessment Ages 0-5 (N = 55)

Ages 6-12 (N = 55)

Ages 13-17 (N = 55)

Total (N = 165)

n % n % n % n % Comprehensive Behavioral Health Assessment*** 52 94.5 51 92.7 37 67.3 140 84.8 Biopsychosocial Evaluation 7 12.7 13 23.6 13 23.6 33 20.0 Psychiatric Evaluation** 3 5.5 12 21.8 14 25.5 29 17.6 Trauma Screen/Assessment** 0 0.0 11 20.0 9 16.4 20 12.1 Behavior Analysis Assessment 5 9.1 5 9.1 5 9.1 15 9.1 Beck Depression Inventory 0 0 6 10.9 6 10.9 12 7.3 Psychological Evaluation 1 1.8 4 7.3 6 10.9 11 6.7 Behavioral/Mental Health Status Exam 2 3.6 2 3.6 6 10.9 10 6.1

***Chi-square significant at the p < .001 level. **Chi-square significant at the p < .01 level.

44


There was no difference by age in the number of assessments a child received, but there

were differences in the types of assessments children received. First, a greater proportion of

younger children (ages 0-5 and 6-12) had a CBHA in their file compared to older children.

There were also differences by age group in the proportion of children who received psychiatric

evaluation and trauma assessment, with these assessments primarily completed on the middle

and oldest age groups. Statistical testing could not be performed for all the different assessments

used due to the small number of children that received many of the assessments.

Child welfare assessments of child needs. In addition to the mental health assessments,

the study team reviewed the Family Functioning Assessments (FFA) that were administered by

child welfare professionals over the duration of a child’s time in care. This included the FFA-

Investigations (FFA-I) completed at the time of intake by child protective investigations, the

FFA-Ongoing (FFA-O) completed by the child welfare case manager at the time of case transfer,

and Progress Updates, to be completed by case managers every 90 days, or more frequently if

needed, throughout the duration of the case. Using the FFA, child welfare workers document the

functioning, needs, and strengths of the family, including the parents, the children, and any other

individuals living in the household. Relevant to the current study, the items related to child

functioning and child needs on the FFAs were reviewed and assessed for their adequacy in

determining children’s mental and behavioral health functioning and needs. Adequacy of the

assessment was evaluated by the review team based on the information provided in the FFA

document concerning the description of functioning and needs and if it was sufficient to

determine the child’s behavioral needs. The team documented the presence and absence of

behavioral health information in the assessments, as well as when inconsistencies were present

within the document.

45


Eighty percent of the cases reviewed had a FFA-I completed by child protective

investigators and a FFA-O completed by case managers in the file. Slightly fewer cases (73.9%)

had completed Progress Updates in the file. For the purpose of this analysis, it was documented

if a Progress Update was completed every 90 days and to assess adequacy, the most recent

Progress Update completed during the study period was reviewed and documented. A similar

proportion of cases had completed assessments in the case file for each of the three age groups.

These findings are summarized in Table 9. While the FFA addresses the domains of child

functioning and child needs including the child’s emotional, behavioral, and mental health needs,

the FFAs by design were found to focus primarily on safety concerns and were not a reliable

source to determine a child’s behavioral health service needs. Some FFAs were comprehensive

with detailed narrative that reflected the current emotional and behavioral functioning and needs

as outlined in the mental health assessments and other case documents, but this was not typical.

Thus, while most case files contained the required assessments, the assessments completed did

not necessarily provide comprehensive information about the child’s emotional and behavioral

functioning or behavioral health needs and often did not incorporate findings or

recommendations from the CBHA or other mental health assessments.

Table 9. Child Welfare Assessments Completed by Age Group

Family Functioning Assessment Ages 0-5 (N = 55)

Ages 6-12 (N = 55)

Ages 13-17 (N = 55)

Total (N = 165)

n % n % n % n % FFA-I Completed assessment in

FSFN 45 81.8 43 78.2 44 80.0 132 80.0

Assessed child functioning 27 49.1 30 54.5 29 52.7 86 52.1 Assessed child’s needs 17 30.9 9 16.4 9 16.4 35 21.2

FFA-O Completed assessment in FSFN

46 83.6 45 81.8 41 74.5 132 80.0

Assessed child functioning* 22 40.0 35 63.6 31 56.4 88 53.3 Assessed child’s needs 19 34.5 30 54.5 24 43.6 73 44.2 Completed assessment in FSFN

43 78.2 40 72.7 39 70.9 122 73.9

46


FFA progress update

Assessed child functioning 24 43.6 33 60.0 30 54.5 87 52.7 Assessed child’s needs 24 43.6 30 54.5 27 49.1 81 49.1

*Chi-square significant at the p < .05 level.

Of the completed FFA-Is that were reviewed (n = 132), approximately 65%11 (n = 86)

were determined to adequately address the child’s emotional and behavioral functioning, but just

slightly over a quarter of them (26.5%, n = 35 of 132 assessments) adequately addressed the

child’s behavioral health needs. Slightly more of the completed FFA-Os that were reviewed (n =

88 of 132 assessments) adequately addressed child functioning, while 55% (n = 73 of 132

assessments) were adequate to determine a child’s mental and behavioral health needs. The

Progress Updates overall provided more thorough documentation, with approximately 71% of

the documented assessments (n = 87 of 122 assessments) considered adequate in assessing child

functioning, and 66% (n = 81 of 122 assessments) adequate to determine the child’s behavioral

health needs. This increase in documentation of a child’s functioning and needs could be

expected as the case managers become more familiar with a child and family and have access to

mental health assessments.

For the most part, the quality of completion of child welfare assessments was similar

across the different age groups. However, a smaller proportion of children in the youngest age

group (0-5 years) were determined to have an adequate assessment of their emotional and

behavioral functioning completed by the case manager compared to both the middle age group

(6-12 years) and the oldest group of children (13-17 years). No other differences by age were

observed with regard to the completion or adequacy of child welfare assessments.

11 The percentages reported in the narrative differ from those reported in Table 9 as they are based on the number of complete assessments documented in the files, and therefore exclude those case files that lacked assessments from the total N. Table 9, on the other hand, presents findings for the full sample, inclusive of case files that lacked FFA documentation.

47


The FFA-O includes a rating of strength and need for each child on a variety of domains,

spanning mental health, physical health, developmental, and relational. The assessment uses a

letter-grade rating scale from ‘A’ (child demonstrates exceptional ability in this area) to ‘D’

(child demonstrates need for intensive support in this area). An A or B rating indicate the child

is doing well in that area and a rating of C or D indicate the child has needs and requires support

in that area. The most relevant items pertaining to children’s behavioral health needs are

included in Table 10. More than half of the children (59.1%) were identified as having

emotional or trauma-related needs (C or D rating) on the FFA-O. Approximately one third of the

children were identified as having needs related to behavior (29.6%) or family relationships

(36.3%). Although the development domain is only completed for children birth to age five,

more than one-third (34.8%) of the children in the younger age group did not have a rating for

development on the FFA-O. A minority of the younger children (23.9%) were considered to

need increased or intensive support for developmental needs.

Table 10. Child Welfare Needs Assessment Ratings by Age Group

FFA-O Child Needs Rating Ages 0 – 5 (N = 46)

Ages 6-12 (N = 45)

Ages 13-17 (N = 41)

Total (N = 132)

n % n % n % n % Emotional/trauma A

B C D NR

13 11 11 9 2

28.3 23.9 23.9 19.6 4.3

2 7

26 7 3

4.4 15.6 57.8 15.6 6.7

4 7

16 9 5

9.8 17.1 39.1 22.0 12.2

19 25 53 25 10

14.4 18.9 40.2 18.9 7.6

Behavior A B C D NR

18 17 3 7 1

39.1 37.0 6.5

15.2 2.2

9 23 6 4 3

20.0 51.1 13.3 8.9 6.7

9 8

15 4 5

22.0 19.5 36.6 9.8

12.2

36 48 24 15 9

27.3 36.4 18.2 11.4 6.8

Development A B C D NR

9 10 8 3

16

19.6 21.7 17.4 6.5

34.8

0 0 0 0

45

0 0 0 0

100

0 0 0 0

41

0 0 0 0

100

9 10 8 3

102

6.8 7.6 6.1 2.3

77.3 Family Relationships A

B C D

16 16 9 4

34.7 34.7 19.6 8.7

8 20 11 3

17.8 44.4 24.4 6.7

4 11 15 6

9.8 26.8 36.6 14.6

28 47 35 13

21.2 35.6 26.5 9.8

48


NR 1 2.2 3 6.7 5 12.2 9 6.8 Rating scale:

A = child demonstrates exceptional ability in this area B = child demonstrates average ability in this area C = child demonstrates some need for increased support in this area D = child demonstrates need for intensive support in this area NR = not rated

When considering both some need for increased support (C rating) and need for intensive

support (D rating) combined, children in the youngest age group (birth to age 5) were rated by

case managers to have the lowest levels of need for the relevant domains. Conversely, children

in the oldest age group typically had the highest needs ratings, except for emotional/trauma

needs, which was slightly higher among the middle age group. However, when only considering

the need for intensive support, younger children were considered to demonstrate need at a higher

proportion than both groups in the behavior domain and a higher proportion than the middle age

group for the emotional/trauma domain. Ratings differed significantly by age group for

emotional/trauma and family relationships. A significant difference in ratings was not observed

among the age groups for behavioral needs.

Child mental health diagnoses and treatment needs. The mental health related

assessments and information present in FSFN and ASK were reviewed to document mental

health diagnoses assigned to each child as well as service recommendations. Table 11 contains

the profile of mental health diagnoses documented in the case files and service recommendations

included in the children’s mental health assessments.

Table 11. Children’s Mental Health Diagnoses by Age Group

Diagnosis Ages 0-5 (N = 55)

Ages 6-12 (N = 55)

Ages 13-17 (N = 55)

Total (N = 165)

n % n % n % n % Adjustment disorders 33 60.0 30 54.5 24 43.6 87 52.7 Attention deficit hyperactive disorder (ADHD)** 4 7.3 16 29.1 12 21.8 32 19.4 Mood disorders (depression, bipolar, etc.)** 4 7.3 9 16.4 18 32.7 31 18.8

49


Trauma-related disorders (including PTSD) 5 9.1 12 21.8 12 21.8 29 17.6 Disruptive, impulse control, and conduct disorders 5 9.1 6 10.9 9 16.4 20 12.1 Anxiety disorders 2 3.6 8 14.5 4 7.3 14 8.5 Developmental or learning disabilities 4 7.3 5 9.1 4 7.3 13 7.9 Oppositional defiant disorder** 0 0.0 3 5.5 9 16.4 12 7.3 Substance use disorders** 0 0.0 0 0.0 8 14.5 8 4.8 Autism spectrum disorders 3 5.5 1 1.8 2 3.6 6 3.6 Number of diagnoses (mean, st. dev.)* 1.54 (1.2) 2.1 (1.3) 2.57 (1.3) 2.05 (1.3)

**Chi-square significant at the p < .01 level. *Chi-square significant at the p < .05 level.

More than half (58.7%, n = 97) of the children had more than one mental health

diagnosis, while 12% (n = 20) were found to have no documented diagnosis or no diagnosis was

given. There were 14 children for whom no diagnostic data were found in the case files.

Slightly more than half of the children (52.7%) were given an adjustment disorder diagnosis.

The types of adjustment disorder included depressed mood, anxiety, disturbance of emotions

and/or conduct, a mixed disturbance, or unspecified type of adjustment. Attention Deficit

Hyperactive Disorder comprised the second most common type of diagnosis given (19.4%),

followed by mood disorders (18.8%), trauma-related disorders (17.6%), and disruptive, impulse

control, and conduct disorders (12.1%). Relatively few children (n = 8) were found to have a

substance use diagnosis. Of these, most were for cannabis-related disorders (n = 6). It is

important to note that a diagnosis indicates meeting the criteria for abuse or dependence;

therefore, lack of a diagnosis does not necessarily mean a lack of substance use.

The number of diagnoses children received differed significantly between the 0-5 age

group and the 13-17 age group, F = 12.014, p < .001. Differences in number of diagnoses

between the 6-12 and 13-17 age groups were not statistically significant, but differences between

the other age group pairings were significant. There were also significant differences in the

distribution of certain diagnoses by age group. First, the diagnosis of Attention Deficit

Hyperactive Disorder (ADHD) was less frequently made for children in the 0-5 age group

50


compared to the 6-12 age group, and the 13-17 age group. Second, mood disorders were

diagnosed more frequently for older children (ages 13-17) compared to children ages 0-5 and

children ages 6-12. Third, the distribution of Oppositional Defiant Disorder (ODD) was most

frequently found among the oldest group of children (ages 13-17). Finally, the distribution of

substance use disorders differed significantly by age group; children who received this diagnosis

were all in the 13-17 age group.

Children’s mental health treatment needs were also determined based on

recommendations in mental health assessments, child welfare assessments, legal documents,

service referrals, clinical summaries, and other documentation found in FSFN and ASK.

Sometimes these needs were directly related to a formal diagnosis, but they were also related to

child emotional and behavioral symptoms and experiences not necessarily connected to or

meeting criteria for a diagnosis. When applicable, mental health needs were correlated with a

recommended and/or referred service as found in the FSFN or ASK documentation, however,

documentation of mental health service receipt or referral were sometimes found in the case file

without indication of the specific need the service was intended to address. Mental health needs

data were not found in the case files for 12 children.

Thirty-five percent (n=58) of the children in the sample were found to have mental health

needs related to trauma. As noted previously, about 17.6 percent (n=29) of the children in the

sample received a diagnosis of PTSD or other trauma-related disorder; the remaining children

without a trauma diagnosis exhibited symptoms related to trauma and traumatic experiences that

required mental health intervention. Trauma-related needs were fairly evenly dispersed across

the age groups. Most of the children experiencing trauma symptoms were noted to have related

mental health needs including emotional instability, family and peer relationship challenges,

51


reactive behaviors, depression, and anxiety. Twenty-nine children (17.8%) were found to have

needs related to anxiety, 32 children (19.4%) had needs related to depression or depressive

symptoms, 24 children (14.5%) had needs related to symptoms of ADHD, and 39 (23.6%)

exhibited maladaptive or concerning behaviors. Twenty-four children (14.5%) were identified as

having mental health service needs concerning family or peer relationships, and 17 children

(10.3%) had needs related to aggression or anger.

Fourteen children (8.4%) were identified as having mental health needs related to sexual

abuse, primarily among the 6-12 and 13-17 age groups, although there were actually 19 children

who had sexual abuse maltreatment allegations. Four of the children with identified needs (all

ages 13-17) were identified as having needs specific to human trafficking victimization. Only

four children were identified as having mental health needs related to symptoms of an autism

spectrum disorder and four related to developmental delays. Other, less commonly identified

needs concerned grief or separation, speech and language, substance use, and one child with

gender identity needs.

Mental health and behavioral health service needs. Concerning mental health services,

documentation of recommended or referred services was found for 153 children (92.7%). The

number of distinct service needs identified and recommended per child by behavioral health

assessors ranged from zero to seven. Differences in the number of service needs identified by

age group did not achieve statistical significance. The most commonly recommended service, by

far, was individual therapy or counseling, which was recommended for 71.5% of the children (n

= 118; see Table 12). Of these children, 14.4% (n = 17) were recommended trauma-focused

therapy, and 11% (n = 13) received a recommendation for a specific evidence-based therapeutic

model, such as Trauma-focused Cognitive Behavior Therapy (TF-CBT). Among younger

52


children, play therapy was commonly recommended (n = 27). Family therapy was

recommended for 52 children (31.5%).

Table 12. Children’s Service Needs Identified by Behavioral Health Providers

Recommended Service Ages 0-5 (N = 55)

Ages 6-12 (N = 55)

Ages 13-17 (N = 55)

Total (N = 165)

n % n % n % n % Individual therapy (psychotherapy, talk therapy)** 25 45.5 48 87.3 45 81.8 118 71.5 Specific evidence-based therapeutic treatments 5 9.1 5 9.1 3 5.5 13 7.9 Trauma-focused therapy 4 7.3 6 10.9 7 12.7 17 10.3 Family therapy 12 21.8 21 38.2 19 34.5 52 31.5 Play therapy** 21 38.2 6 10.9 0 0.0 27 16.4 Evaluation (psychiatric, psychosocial, etc.)* 9 16.4 5 9.1 16 29.1 30 18.2 Behavior analysis 10 18.2 9 16.4 3 5.5 22 13.3 Medication management 4 7.3 8 14.5 7 12.7 19 11.5 Targeted case management 2 3.6 1 1.8 7 12.7 10 6.1 Therapeutic visitation 3 5.5 1 1.8 3 5.5 7 4.2 Substance abuse treatment 0 0.0 0 0.0 3 5.5 3 1.8 Specialized therapeutic foster care or group home 1 1.8 0 0.0 2 3.6 3 1.8 SIPP or residential treatment 0 0.0 1 1.8 1 1.8 2 1.2 Other (group therapy, occupational therapy, etc.) 5 9.1 5 9.1 4 7.3 14 8.5 Number of services (mean, st. dev.) 1.64 (1.5) 1.96 (1.1) 2.20 (1.0) 1.93 (1.2)

**Chi-square significant at the p < .01 level. *Chi-square significant at the p < .05 level.

Thirty children (18.2%) were recommended for additional evaluation and assessment,

including psychiatric and psychological evaluations and behavioral assessments. Behavior

analysis related services were recommended for 22 children (13.3%) including applied behavior

analysis and behavior management. Twelve of the 14 children identified as having sexual abuse

related needs were referred for mental health services specifically to address sexual abuse or

suspected sexual abuse. Furthermore, the four children with human trafficking concerns were

referred for human trafficking specific services. Other, less frequently recommended services

included child-parent psychotherapy, dyadic therapy, therapeutic visitation, grief counseling,

targeted case management, day treatment, residential inpatient treatment, substance abuse

services, art therapy, and occupational and speech therapy.

53


There were several differences in the distribution of recommended services by age group.

In particular, there were differences in the distribution of individual therapy, play therapy, and

evaluation. Individual therapy was more frequently recommended for children ages 6-12, and

for children ages 13-17, compared to children ages 0-5. In contrast, younger children (ages 0-5)

were more frequently recommended to receive play therapy compared to children ages 6-12, and

children ages 13-17. Finally, additional evaluation services, such as psychiatric, psychological,

or biopsychosocial evaluation, were most commonly recommended for the oldest group of

children (ages 13-17), although differences were only significant compared to the 6-12 age

group.

The case files were also reviewed for evidence of service receipt connected to the specific

behavioral health needs identified. If receipt of the recommended service was documented in the

child’s record, this was noted on the protocol, however, lack of documentation does not mean the

service was not provided, only that there was no evidence to assess whether or not it was

provided. There were 263 mental and behavioral health needs documented for the sample, with

a slightly larger portion of these attributed to the 13-17 age group (34.6%, n = 91) and 6-12 age

group (34.2%, n = 90) compared to the 0-5 age group (31.2%, n = 82). The files contained

evidence of service receipt for approximately 81% of the identified needs (n = 213). A greater

proportion of children in the 13-17 age group had evidence of service receipt in their file (85.7%)

compared to the 6-12 age group (81.1%) and the 0-5 age group (75.6%).

Estimate of overall child welfare population needs. To estimate mental and behavioral

health needs for the overall population of children in licensed care in the Southern Region during

the period under investigation (2016-2018), the percentages of need found through the case

record reviews were applied to the total number of children in licensed care who received at least

54


one mental health service during this timeframe. A limitation is that this does not address the

possibility that there may have been some children in care with mental health needs who did not

receive services during this period. Administrative data indicate that, of 4,855 children with out-

of-home care episodes during this timeframe, approximately 67% (3,257 children) received at

least one mental health service. We cannot ascertain whether the remaining children had no

mental health needs, or whether their needs were not identified and addressed.

Children in the overall child welfare population that received mental health services in

the Southern Region were not evenly distributed across the age groups. The greatest proportion

of children were ages 6 to 12 (40.2%, n = 1,310), followed by children ages 0 to 5 (32.5%, n =

1,057), and children ages 13 and up (27.3%, n = 890). Table 13 provides diagnostic and service

needs estimates by age group for the total population. Estimated numbers of children with a

given need were rounded to the nearest whole number. Some discrepancies are noted, for

example, between the rate of substance use disorder diagnosis and the rate of substance abuse

treatment recommendations. Thus, service needs may be underestimated through this

methodology, as they are based on the recommendations that were found in case records and do

not account for service needs that might not have been documented.

Table 13. Estimate of Child Mental and Behavioral Health Needs Diagnosis Ages 0-5 (N = 1,057) Ages 6-12 (N = 1,310) Ages 13-17 (N = 890)

%1 n2 %1 n2 %1 n2

Adjustment disorder 60.0 634 54.5 714 43.6 388 ADHD 7.3 77 29.1 381 21.8 194 Mood disorder 7.3 77 16.4 215 32.7 291 Trauma-related disorder 9.1 96 21.8 286 21.8 194 Disruptive, impulse, conduct 9.1 96 10.9 143 16.4 146 Anxiety disorder 3.6 38 14.5 190 7.3 65 Developmental/learning disorder 7.3 77 9.1 119 7.3 65 Oppositional Defiant Disorder 0 0 5.5 72 16.4 146 Substance use disorder 0 0 0 0 14.5 129 Autism spectrum disorder 5.5 58 1.8 24 3.6 32 Service Needs Ages 0-5 (N = 1,057) Ages 6-12 (N = 1,310) Ages 13-17 (N = 890)

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%1 n2 %1 n2 %1 n2 Individual therapy 45.5 481 87.3 1,144 81.8 728 Play therapy 38.2 404 10.9 143 0 0 Family therapy 21.8 230 38.2 500 34.5 307 Mental health evaluation 16.4 173 9.1 119 29.1 259 Behavior Analysis 18.2 192 16.4 215 5.5 49 Medication management 7.3 77 14.5 190 12.7 113 Targeted case management 3.6 38 1.8 24 12.7 113 Substance abuse treatment 0 0 0 0 5.5 49 STFC, STGC, or SIPP 1.8 19 1.8 24 5.5 49

1Percentages derived from the case record reviews; refer to Tables 6 and 7. 2Estimated number of children with need; calculated by multiplying the total population size (N) by the proportion expected to be affected (%).

Stakeholder perception of mental and behavioral health needs. Findings from

behavioral health provider interviews, child welfare case manager focus groups, and the case

management survey were reviewed to provide context to the child mental and behavioral health

needs and services identified through the case file reviews. The findings described here speak to

perceived needs only, and not necessarily the actual service capacity of the local system of care.

Service capacity and utilization are examined next in the subsequent sections. Overall, the

perception of unmet behavioral health service needs in the region was high. Considering the

modality of service provision, behavioral health provider respondents emphasized the need to

utilize a family-level perspective, expressing the concern that focus was often placed on treating

the child rather than the family system and family trauma from which a child’s behavioral health

needs often originate. This expressed need for family therapy also stressed the desire for

increased inclusion of and communication with the reunifying parents in the child’s treatment,

when possible. The need for comprehensive mental health assessments at the time of protective

service intake was also emphasized.

Behavioral health providers further noted an absence of evidence-based models being

used in the region to address behavioral health needs, but did not specify the type of

interventions that were lacking, other than a need for greater emphasis on trauma-based

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treatments. Residential care for mental health and substance abuse treatment, behavioral health

services for children who also have developmental disabilities, services for children with autism,

and crisis stabilization services to respond to suicidal ideation and high-risk behavior were also

named as needing more resources. The need for residential services were reported to be greatest

in Monroe County, where respondents shared there were no existing residential services, but

Dade County also faced challenges in this area with limited locations to serve such a large

population. Furthermore, they reported a lack of specialized services for children in need of

higher levels of care, such as therapeutic foster care, which often prevented them from keeping

such children in the community. These views were consistent with case manager focus group

findings, in which respondents described non-existent specialized therapeutic foster care and

inpatient services in Monroe County, and a need for more higher-level of care services in Miami-

Dade County, describing availability as limited and inadequate compared to the level of need.

Another need that emerged from the behavioral health provider interviews was use of a

wraparound approach that treated multiple needs impacting long-term well-being and emotional

stability through an array of behavioral and developmental services including speech,

occupational, and physical therapy. Child welfare case manager focus group respondents

expressed a similar need for increased access to occupational therapy, speech therapy and autism

behavior therapy.

In addition, while children might enter into care with particular mental and behavioral

health needs, providers described a need to also provide children with services and support to

cope with the loss and discontinuity of multiple providers during their time in care, potentially

including changes in child welfare case managers, caregivers, teachers, and therapists. Other

recommendations included provision of extracurricular activities to provide emotional well-

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being and social support to children, with the intention that they could prevent further mental

health problems from developing.

Another area of concern, particularly among case managers, was with regard to the

effectiveness of available services to meet the behavioral health needs of children in care. As

part of the case management survey, case management professionals rated the effectiveness of

local behavioral health treatment services, from highly effective to largely ineffective, for 16

specific behavioral health needs (See Appendix E for full survey results). Case management

perceptions of the effectiveness of treatment services varied considerably, however, no services

were rated by the majority of case management respondents as highly effective. Very few

respondents (e.g. fewer than 15%) rated the available services as highly effective for any of the

behavioral health needs assessed. Treatments services for anxiety, mood disorders,

attention/hyperactivity, and attachment issues were rated as fairly effective by a majority of

respondents. Even for these conditions, however, a considerable proportion of respondents did

not believe services were particularly effective. Services perceived to be least effective by the

highest percentage of respondents included those for severe/complex trauma, psychosis,

disruptive behavior, conduct problems, victims of sexual abuse, children exhibiting self-harming

behaviors, victims of human trafficking, specialized therapeutic placements, and residential care.

These concerns about the effectiveness of services mirror, to some extent, the concerns

expressed by providers about the lack of evidence-based treatment utilization.

Children’s Behavioral Health Service Array

Findings presented in this section pertain to the identified provider network and array of

behavioral health services available to children in licensed foster care. This includes (1) the

number, array, and availability of community-based services and providers of treatment services

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accessible to placement caregivers, (2) the number, array, and availability of higher end (e.g.

specialized therapeutic placements) and inpatient services for children with higher level of care

needs, (3) the number, array, and availability to children in licensed care of service supports that

utilize trauma-informed and evidence-based practices, and (4) the number, array, and availability

to children in licensed care of behavioral health mobile response interventions. Additionally,

barriers and challenges identified by behavioral health providers and case management staff that

may impact service availability or limit access to care are described.

Description of provider network and service array. The children’s behavioral health

provider network for the Southern Region was identified by (1) reviewing Sunshine Health’s

Child Welfare Specialty Plan (CWSP) provider directory, (2) reviewing the Managing Entity’s

champions for child welfare provider network, (3) administration of the behavioral health

provider survey (n = 20 responses), and (4) internet searches to find service information for

providers who did not respond to the survey. Data collection focused on gathering information

on the variety of services available within the community, including the provision of mobile

response interventions, as well as the types of children’s behavioral health needs the available

services are designed to address. Limited information was available for some providers; thus,

this section provides an approximation of the overall service array and capacity.

Outpatient services. A total of 75 provider agencies in Miami-Dade County and five

provider agencies in Monroe County were identified that offer outpatient behavioral health

services to children in licensed foster care. Most (92.5%) of these providers were on the CWSP.

Other common funding sources besides Medicaid that survey respondents reported included the

Managing Entity and DCF. Findings indicate that Miami-Dade County has a fairly wide and

robust array of services, while Monroe County has a more limited array of services. These

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findings, shown in Table 14, are limited to the data that could be obtained through the study, and

as a result may under-represent system capacity due to limited availability of data for some

providers. The most widely available services, based on the number of agencies identified as

providing each service, included individual therapy, psychiatric services, family therapy, case

management, mental health assessments (CBHA, bio-psychosocial, psychiatric evaluation, etc.),

and group therapy. There were also 12 agencies in Miami-Dade and two agencies in Monroe

that explicitly reported providing intensive outpatient services. Although there were few

agencies that provide mobile response services, no issues with capacity were reported for either

county; copies of their recent monthly reports (July 2019 – March 2020) indicate that average

response times were under 2 hours for Miami-Dade and under 30 minutes for Monroe.

Table 14. Outpatient Services Provided in the Southern Region Miami-Dade Monroe

Outpatient Services1 # of providers

Estimated capacity2

# of providers

Estimated capacity2

Mental Health Assessments 26 45,022 4 5,574 Individual therapy/counseling 40 3,463 4 279 Family therapy 32 8,320 3 780 Group therapy 23 1,991 0 0 Behavior analyst/ behavior management 13 1,126 1 70 Case management 25 2,165 1 70 Psychiatry/medication management 33 2,857 3 209 Psychosocial rehabilitation 13 1,126 0 0 Substance abuse counseling 16 1,385 2 139 Crisis intervention/management 4 6,926 1 1,394 Intensive outpatient services/ TBOS 12 1,039 2 139 Mobile response services 2 3,463 1 1,394

1There were 17 agencies for whom no information on services could be obtained. It is also possible that information obtained through provider websites about the services they offer was incomplete; the numbers in the table are based on the available data. 2Estimated number of children that can be served per year. See below for explanation of how estimates were calculated.

Determining the actual capacity of these services was more challenging, as most provider

websites did not offer extensive information on staffing, caseloads, or the number of clients

served, and the number of survey responses providing this information was limited (n = 23; see

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Appendix D for full survey results). Of the limited data that could be gathered, it was apparent

that agencies vary considerably in size, from small agencies with 5 or fewer front-line staff to

large agencies with 25 or more front-line staff. Average caseloads also varied somewhat,

generally ranging from 10 to 35 children. Similarly, duration of services could vary greatly,

depending on the child’s need, with providers reporting average durations ranging from three to

twelve months for most therapeutic services. The primary exceptions were mental health

assessments, crisis intervention, and mobile response services, all of which are typically short-

term interventions (24-72 hours).

To provide a basic estimate of the overall service capacity, we applied a formula of an

average caseload of 20 children, average of 10 staff per agency able to provide a given service,

and average service duration of nine months for therapeutic services. For mental health

assessments, crisis intervention, and mobile response services, the formula used was an average

of 10 children per staff per week and an average of 10 staff per agency. Next, since most

agencies identified do not exclusively serve children, but also serve adults, it was presumed that

a considerable portion of their capacity would be consumed by adult clients. The adult

population for Miami-Dade County is 2,156,795 compared to approximately 604,786 children.

National estimates of serious mental illness rates in adults is 4.5% (NIMH, 2019), and rates of

serious emotional disturbance in children range from 4.3% to 11% (Ringeisen, et al., 2017; we

assumed an average rate of 8%). These calculations yielded estimates of 97,055 adults and

48,383 children for Miami-Dade County with behavioral health needs, which indicate that

children would be expected to comprise roughly one-third (33.3%) of a provider’s clients. The

same calculations conducted for Monroe County, which has a smaller child population, indicate

that children would be expected to comprise approximately 26.8% of a provider’s clients. These

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percentages were therefore applied to the total estimated service capacity12 to provide an

estimate specific to capacity to serve children. An important caveat is that these estimates do not

account for how many non-child welfare clients agencies may serve, which would also likely

consume a considerable portion of a provider’s capacity, but only provide an overall estimate of

how many total children can be served annually.

Specialized therapeutic placement services. The availability of services for children

requiring a higher level of care was much more limited. Notably, these services were only

available in Miami-Dade County. Four providers were identified who offered specialized

therapeutic foster care (STFC) and one provider was identified who provided therapeutic group

care (STGC). On average, duration of these services was reported to range from nine to twelve

months. While the number of licensed beds reported by the CBC was fairly substantial (see

Table 15), there were a couple caveats. First, the CBC explained that the STFC providers accept

children from all over the state; therefore, the 133 licensed beds were not reserved for children

from Miami-Dade County or even the Southern Region, although the CBC is working to change

this process. Second, the CBC has encountered issues with STFC homes not accepting children

who have particularly severe needs, which has resulted in having a wait list of children for STFC

despite having open beds. To address this challenge, the CBC has been working on developing a

Qualified Residential Treatment Program that will be able to serve children with higher level of

care needs who cannot be placed in STFC.

Table 15. Therapeutic Placement Services Provided in the Southern Region Specialized Therapeutic Placements (Miami-Dade only) # of providers # of beds Specialized Therapeutic Foster Care 4 133 Therapeutic/Residential Group Care 1 6

12 Excluding family therapy, since it is already assumed to be an estimate of the number of families that can be served.

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Inpatient services. The array of inpatient services identified included crisis stabilization

units, the Statewide Inpatient Psychiatric Program (SIPP), Baker Act receiving facilities and

acute care psychiatric units, and other residential treatment programs. With the exception of one

children’s crisis stabilization unit and one SIPP, these services were not exclusively for children,

and it was unclear whether children were served in separate units or simply mixed with adult

patients, nor was any specificity provided as to the number of beds available to children versus

adults. Some facilities did not specifically state whether they served children, so it was difficult

to ascertain the actual number of providers. Unless a facility explicitly stated that it served

adults only, it was counted. Notably, inpatient services were only available in Miami-Dade

County. Children who require acute care under the Baker Act are transported from Monroe

County to Miami-Dade County. In FY17/18, 37 children were involuntarily examined under the

Baker Act (it is unknown how many were admitted).

Table 16. Inpatient Services Provided in the Southern Region Inpatient Services (Miami-Dade only) # of providers # of beds Children’s crisis stabilization unit 1 16 Crisis stabilization unit – mixed child and adult1 2 44 Statewide Inpatient Psychiatric Program (SIPP) 1 44 Other inpatient/residential treatment1,2 9 184

1 Number of children’s vs. adult beds not specified. 2Includes facilities that serve both children and adults. Information on number of beds could not be found for 6 facilities.

Trauma-informed and evidence-based practice. Information on the provision of trauma-

informed and evidence-based services was limited and difficult to ascertain beyond what was

reported on the provider survey, however, some provider websites did identify specific treatment

modalities that they employ. For the most part, survey respondents reported having training

requirements in place pertaining to trauma-informed care. A majority of respondents indicated

that all staff at their agency receive trauma-informed care training (60.9%) or most staff receive

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training (30.4%). Two agencies (10%) reported that only “some staff” receive trauma-informed

care training. Another six providers were identified that mentioned provision of trauma-based

services on their website. The lack of a specific statement about trauma-informed services does

not necessarily mean a provider does not provide such services, since many provider websites

lacked specificity regarding their services.

Regarding the use of evidence-based practices, a total of 19 distinct treatment modalities

were identified through the survey and provider websites. Those most frequently identified

included Cognitive Behavior Therapy (CBT, n = 17), Trauma-Focused Cognitive Behavior

Therapy (TF-CBT, n = 9), Motivational Interviewing (n = 8), Solutions Focused Behavior

Therapy (SFBT, n = 5), Dialectical Behavior Therapy (DBT, n = 5), Play Therapy (n = 5), and

Child-Parent Psychotherapy (CPP, n = 4). The only explicitly trauma-based treatment model

identified was TF-CBT. (For a full list of treatment modalities identified, refer to Appendix C)

While a wide array of evidence-based practices and treatment modalities was identified, there

were a limited number of providers reporting the provision of these services.

Services for specific children’s behavioral health needs. Information was also gathered

with regard to the availability and provision of services to address specific children’s behavioral

health conditions and needs. Findings suggest that the capacity of the behavioral health system

varies by the particular need in question. Children’s behavioral health needs for which capacity

was highest (e.g. more than 20 providers reported services to address the particular need)

included attention deficit hyperactive disorder, anxiety disorders, depression and mood disorders,

trauma-related disorders, outpatient substance abuse treatment, and (non-specified) behavior

problems. Moderate service capacity (e.g. 10 to 20 providers reported services to address the

particular need) was found for attachment disorders, adjustment disorders, impulse control

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issues, oppositional defiant disorder, children exhibiting self-harming behavior or suicidal

ideation, psychosis, autism spectrum disorder, developmental disabilities, and treatment for

victims of sexual abuse. Behavioral health needs for which capacity was most limited (e.g.

fewer than 10 providers reported services to address the particular need) included services for

serious conduct disorders, eating disorders, personality disorders, gender or sexual identity

issues, and treatment for victims of human trafficking.

Stakeholder perceptions of service availability and accessibility. Although findings

indicate that an extensive provider network exists for children’s behavioral health services in the

Southern Region, there are a number of factors that may impact how the service array is

experienced by those in the foster care system. Key stakeholders, particularly behavioral health

providers and case management staff, were asked to share their perspectives regarding the

availability and accessibility of services for children in licensed foster care. The findings point

to a number of gaps and challenges in service provision.

Availability and array of services. Respondents described variability in the availability

of children’s behavioral health services, depending on the particular service or behavioral health

need. Common themes emerged across behavioral health providers and child welfare case

managers. Access to mental health evaluations and assessments was reported to be somewhat

limited, or associated with considerable wait times of up to 30 days, according to both providers

and case managers. Outpatient services, such as individual counseling or therapy, were generally

reported to be readily available, but options for children requiring higher levels of care were

more limited. Access to residential care for mental health and substance abuse, behavioral health

services for children who also have developmental disabilities, services for children with autism,

and crisis stabilization (and further, services to respond to suicidal ideation and high-risk

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behavior such as cutting) were identified as needing more resources. Services for non-English-

speaking clients were also mentioned as being inadequate, particularly in reference to Creole and

in some cases Spanish or indigenous dialects.

Providers in Monroe County, in particular, reported having limited service options and

indicated that they did not feel there were adequate services in place for youth with behavioral

health needs and developmental disabilities. They reported that many of their services were

outsourced to neighboring counties, and that lack of inpatient or specialized services for children

with higher levels of need, such as therapeutic foster care, was particularly challenging. The

absence of a Baker Act receiving facility in the area was another noted issue.

While the need for residential services was reported to be greatest in Monroe County,

Miami-Dade also faced challenges in this area with limited locations to serve such a large

population. Limited availability, or altogether lack of services, made it difficult, and sometimes

impossible, to keep children with higher levels of need in the local community. When youth

need to be sent out of town for treatment due to a paucity of localized services, providers

expressed that it disrupts the relationship between the case manager and therapist attached to the

youth’s care, further complicating coordination of services. In addition, some agencies

expressed that their facilities were not equipped to keep up with the demand of children in need

of residential services.

Case managers reiterated what was shared by providers regarding the lack of specialized

therapeutic foster care and inpatient services in Monroe County, and limited availability in

Miami-Dade County, noting that their job often entailed finding creative solutions to combat

structural barriers to care. Case managers also expressed frustration with a limited variety of

services, describing what they perceived to be an over-reliance on traditional talk

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therapy/counseling and psychiatry, of which service availability was more plentiful. These

sentiments were echoed by some behavioral health providers, who expressed that many children

were in need of, or would benefit from, additional services in combination with individual

therapy, such as mentoring, occupational therapy, and extracurricular activities, as well as greater

incorporation of a wraparound services approach.

Responses from the case management survey, furthermore, indicated that most

respondents perceived the availability of children’s behavioral health services was inadequate

compared to the need13, and that services were often difficult to access14. This finding was

consistent across 16 behavioral health needs that respondents were asked about, although it was

more pronounced for some needs than for others. (For full survey results, see Appendix E). The

greatest gaps reported in terms of availability and accessibility were for services to address

severe conduct problems, specialized therapeutic placements (e.g. STFC or STGC), residential

care, services for disruptive behaviors, services for children experiencing psychosis, services for

children who have experienced human trafficking, and services for children exposed to severe or

complex trauma. For each of these needs, a significant majority of respondents reported that

services were largely unavailable and difficult to access. Case managers were unanimous in

their beliefs that significant gaps in behavioral health services centered upon the lack of available

behavioral health services, particularly for children with severe mental health diagnoses, and lack

of therapeutic homes.

Wait lists. Beyond the actual array of services within the existing provider network, a

number of barriers were identified that limited the availability and accessibility of services. Wait

13 Availability was defined as the extent to which services are offered and readily available (e.g. without a waitlist) in the community 14 Accessibility was defined as the extent to which children in foster care can actually access the services, taking into account factors such as cost, insurance coverage, provider hours and location.

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lists for services were reported to be a common challenge. Long wait times were noted as a

challenge by a number of respondents on the case management survey and were also reported

during the case manager focus groups. Responses on the provider survey also confirmed that

some services incurred wait lists, which could be up to four weeks.

When asked directly about wait lists during interviews, behavioral health provider

responses were mixed. However, the reason for the bulk of the no-wait list responses may be

semantics or procedural reasons rather than service needs being met. A minority of respondents

said they did not have a waiting list and reported very short timeframes, for example, “within

two weeks,” that assessment and services started. Generally, interviewees did list wait times for

services such as specialized therapeutic foster homes, specialized medical services, neuro-

psychological testing, residential substance abuse, adolescent residential facilities that were not

in high crime neighborhoods, educational services for academic needs and, in Key West,

children’s outpatient services. A range of one to three months to receive certain services was

given if wait lists were reported.

A number of providers, furthermore, described an articulated strategy to provide some

type of services to a child when high end or specialized services were clinically indicated but

currently full. A provider explained:

We don’t really have any wait list, so what we’ve been doing to manage is we will provide some level of care while people are waiting for that higher level of care. So for example, the Community Action Team is a really intensive program that was created by the State of Florida in order to keep kids out of higher levels of care from going to residential, but we can only have 35 youth in that program at a time, so if there’s somebody who we feel meets the criteria for that program, but that program is full, we will still provide Therapeutic Behavioral On-Site Services, or even crisis counseling. We can always provide something, so there really isn’t the wait list, per se, but that also doesn’t necessarily mean that-that youth couldn’t benefit from having something more intensive.

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Another respondent reiterated that high-end services were not always available when needed and

that children who fall into this category of service need may not be getting services that are

clinically appropriate. As this interviewee stated, “They will just kind of get something else.

They would be referred to a community mental health outpatient service that might be able to

intake them quickly, but then, that’s not really going to address the issue.” Another response to

the waiting list question indicated that agencies may be refusing referrals if they cannot serve

children immediately. So, in other words, they do not have a waiting list for services because

agency policy does not allow them to keep one despite population need for services.

Transportation. Additional barriers to accessing care identified by respondents included

transportation and the ability or willingness of foster parents to take children to appointments.

Provider and case management respondents from Miami-Dade noted that the county is quite

large geographically combined with heavy traffic, and as a result, accessing certain services may

require a great deal of travel and time. This can be a considerable burden on foster parents,

especially if they have several children in their care. At the same time, case managers expressed

frustration that many foster parents simply seemed unwilling to take children to appointments,

and expected case managers to take on this responsibility.

Several providers emphasized providing services in the community, for example, going

to children’s schools or homes, rather than conducting appointments in the office. One provider

noted that they are co-located within the schools in their catchment area. Another provider

reported having mobile crisis response services. A number of providers also reported the

provision of in-home individual and/or family therapy on the provider survey or on their

agency’s website (n = 11). To the extent possible, case managers reported that they tried to

identify providers who were close to the child’s residence, or utilize in-home service providers as

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much as possible. Additionally, some providers reported offering flexible services hours, such as

evenings or weekends, in order to work around foster parents’ schedules. Providers did not

speak to the extent to which school or home-based services were adequately available throughout

the region, but case managers indicated that there was a need for more of these services. Thus,

increased availability of in-home services and increased implementation of behavioral health

interventions within the school system were offered as recommendations for improving access to

services. One provider explained, “Our program may be in one school, but we’re not in all of the

schools and the counselors tend to have a big caseload.” Another suggested solution was to

expand the use of telehealth technologies to provide services virtually.

Medicaid restrictions and eligibility. Among case managers, the bureaucratic processes

surrounding Medicaid-funded services was a major point of contention. Case managers

criticized that Medicaid requirements and restrictions often blocked or limited access to

behavioral health services for children. One way in which this occurred was with limitations on

the frequency or amount of services that Medicaid would approve. The following excerpt

provides an example of the challenges experienced by case managers:

You know, Medicaid only gives you maybe an hour a month or something like that. It’s like, it’s awful. At max, you’re looking at maybe two to three hours a month for speech therapy on Medicaid’s approval. So, it’s just certain things, you know, you’re fighting. Like she was saying earlier, you’re fighting about whether or not are they doing it because the child really needs it, or is this a money issue? And the things that they really need, Medicaid isn’t covering.

Respondents expressed the need for access to a variety of services such as occupational therapy,

speech therapy, and behavior therapy, however, the funding needed for certain services was

limited and difficult to get approved.

Frustrations regarding Medicaid also included the fact that children typically needed to

have a mental health diagnosis in order to receive services. Case managers frequently had

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children on their caseload who exhibited behavioral issues, but lacked a diagnosis, thereby

precluding them from accessing services that could prevent the escalation of their condition.

While other funding sources for services exist, such funding was limited and respondents

expressed that they received considerable resistance from the case management agencies and the

CBC whenever they requested approval to pay for services that Medicaid did not cover.

Eligibility criteria reported by behavioral health providers varied somewhat by service type, but

most commonly, respondents reported that services required a mental health diagnosis, an

identified behavioral health concern, or a court order or referral, and were paid for through a

variety of funding sources, including Medicaid, DCF, and the managing entity. They could not

speak, however, to the process case managers had to go through to get services approved if they

were not Medicaid eligible.

Provider funding and resources. Another pressing issue raised by providers was being

understaffed, and a lack of adequate funding and resources to meet their staffing needs.

Respondents stressed that providers did their best within current resourcing to meet children’s

needs, but both foster parent and staff recruitment were significant issues. This was especially

true for Monroe County, where it was reported they struggled with staff shortages including a

shortage of licensed mental health clinicians, a limited number of service providers, and an

inability to provide compensation commensurate with the local cost of living. Furthermore,

agencies were still dealing with the impact of Hurricane Irma, which had resulted in substantial

housing loss and the relocation of considerable numbers of staff. As one respondent

summarized: “The number one thing is people. We need people. We need the therapists. We

need the case workers. We need the support coordinators. We need people.” It was reported

that it was difficult to attract and retain a skilled workforce in Monroe County because they were

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in the midst of a housing crisis, and lacked affordable housing options for the professionals they

desperately needed. They described a severe shortage of workers to manage the Key Largo,

Marathon, and especially Key West areas.

Challenges with staff shortages, and closely related, high turnover rates emerged as an

issue for Miami-Dade County as well. One of the driving factors reported by respondents was

inadequate compensation. It was noted that Medicaid reimbursement rates were extremely low,

and had not changed in many years, despite inflation and increasing costs of living. Providers

further observed that low Medicaid rates had the effect of suppressing private insurance

reimbursement rates, with private insurance companies increasingly “following suit.” In

addition, respondents noted that working with the foster care population was particularly

challenging due to the high level of trauma plus the requirements placed on providers by the

child welfare system. The end result was that providers were tasked with very challenging and

burdensome work for marginal pay, thus fueling staff burnout and high turnover. There was also

recognition that the same issues (high demand job coupled with poor compensation) exist for

case managers and must be addressed throughout the system.

The implications of staff shortages and frequent turnover, as described by providers,

were: (1) children lack consistency and must continually start over each time they get a new

therapist or case manager, which could result in a loss of progress that had been made, and (2)

overburdened staff may not get to know the children on their caseload particularly well, and

therefore cannot adequately assess or address the needs of those children. Thus, respondents

expressed a strong need to provide greater supports, including better compensation, to frontline

workers in order to retain a skilled workforce.

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Effectiveness. Additionally, case managers indicated concern regarding the effectiveness

of many children’s behavioral health services. Very few survey respondents (e.g. less than 15%)

rated the available services as highly effective for any of the behavioral health needs assessed.

Treatments for anxiety, mood, attachment, and attention deficit and hyperactivity disorders were

considered to be at least fairly effective by a majority of respondents. Even for these conditions,

however, a considerable proportion of respondents did not believe services were particularly

effective. Services perceived to be least effective included those for severe/complex trauma,

psychosis, disruptive behavior, conduct problems, victims of sexual abuse, children exhibiting

self-harming behaviors, victims of human trafficking, specialized therapeutic placements, and

residential care.

These findings should be interpreted with caution, since case managers do not necessarily

have the tools or knowledge to accurately assess the effectiveness of available treatment

interventions. In fact, during focus groups, case managers indicated a lack of knowledge or

awareness as to the availability of evidence-based treatment interventions, and generally did not

seem to have access to information about the effectiveness of particular service options. Their

perceptions of services tended to be based more on positive experiences with a given provider.

At the same time, their perceptions of service effectiveness likely impact referral decisions, and

therefore are extremely important.

Related to these findings, behavioral health providers expressed concern that case

managers lack a working knowledge of children’s mental health issues and the evidence base for

various treatment services, noting that this may impact whether and how they follow up on

assessment recommendations. As one provider observed,

It’s very difficult to make appropriate referrals if you’re not – if you don’t know what the child needs or if you don’t know what the services are… What specific evaluations are

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for, what specific therapies are for. Being trained in evidence-based therapy, being able to ask for evidence-based treatment, knowing how to determine if a child is making progress in the treatment.

This was reiterated by case managers during the focus groups, who expressed that, for the most

part, CBHAs did not provide recommendations for specific types of therapy or treatment models,

such as particular evidence-based practices. Findings from the case file reviews further

corroborated what was reported by providers and case managers; a minority of the cases

reviewed included recommendations in the CBHA for specific services or treatment modalities,

while the majority contained generic service recommendations such as ‘individual therapy’ or

‘family therapy.’ Providers also suggested that lack of awareness with regard to the services that

are available in the community may be a barrier. Case managers and foster parents may not be

aware of the full array of different service options available in the local community, which could

result in underutilization of some services that may be beneficial to children in licensed care.

Furthermore, the extent to which evidence-based treatments are available within the

community was another noted challenge. Behavioral health providers recommended that greater

emphasis be placed on training and certification in evidence-based and trauma-informed

practices. One provider voiced, “There’s a number of evidence-based models that aren’t actually

being used in Miami,” indicating that for families in foster care, access to evidence-based

practices may be limited. While some providers reported that staff at their agencies specialize in

particular evidence-based models and there are expectations around certification and use of those

models, they were less certain about how widespread such practices were throughout the service

system. Information gathered through the provider survey and review of provider websites

identified a number of evidence-based treatment modalities in use, as described above, but these

were reported by a relatively small number of providers compared to the overall provider

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network. Identification of specific trauma-based treatment modalities was especially limited.

Respondents recommended that all providers working with the child welfare population should

be trained in specific evidence-based trauma interventions.

Service Utilization Patterns for Children in Licensed Care

This final section examines behavioral health service receipt among the full sample of

children who received at least one behavioral health service while in out-of-home care during

calendar years 2016, 2017, and 2018. The analysis includes numbers of service encounters,

types of services, and service expenditures. Comparisons between Miami-Dade and Monroe

Counties were made when possible and appropriate to do so.

Child Characteristics. Table 17 contains the characteristics of the final sample of

children served in out-of-home care who received behavioral health services. The average age

was nine years old and there were slightly more females than males. The majority of children

were Black and came from single parent homes. Absence of care, neglect, and parental

substance abuse were the most common forms of maltreatment. Over 95% of the children live in

Miami-Dade County. Sixty-eight percent (3,125/4,604) of children receiving child welfare out-

of-home services in Miami-Dade received behavioral health services compared to 52.6%

(132/251) of children in Monroe County.

Table 17. Final Sample Characteristics Number of children % of children/Mean

Age 3,257 9.02

Child gender Female 1,668 51.2 Male 1,589 48.8

Child race Black 1,777 54.6 White 1,352 41.5

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Other 136 3.9

Family Structure Married Couple 349 10.7 Single Female 1,739 53.4 Single Male 169 5.2 Unmarried Couple 706 21.7 Unable to determine 294 9.0

Type of Maltreatment Sexual abuse 158 4.9 Physical abuse 456 14.0 Neglect 1,168 35.9 Absence of care 1,379 42.3 Domestic violence 467 14.3 Substance abuse problems 912 28.0

County Miami-Dade 3,125 96.0 Monroe 132 4.0

Diagnoses. The primary and secondary mental health diagnoses on each encounter were

used to establish the most frequent diagnoses received by each child15. The most frequent

mental health diagnosis was determined to be the child’s primary diagnosis, while the second

most frequent mental health diagnosis was determined to be the child’s secondary diagnosis. In

addition, it was determined whether the child had received a substance abuse diagnosis on any

encounter. Table 18 contains the profile of mental health diagnoses. Over 62% of the children

had a primary diagnosis of reaction to stress and/or adjustment disorder. Other primary

diagnoses included ADHD (13.2%), mood disorders (9.8%), and conduct disorders (9.4%). Fifty

percent of children had multiple mental health diagnoses, while 50% only had one mental health

diagnosis. Twelve percent of children had a reaction to stress and/or adjustment disorder as the

secondary diagnosis while 12.4% had ADHD as a secondary diagnosis. In other words, 12.4%

15 A diagnosis on a claim or encounter may be a confirmed diagnosis or a rule-out diagnosis (i.e., a suspected diagnosis to be confirmed or rejected based on assessment).

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of the children had reaction to stress and/or adjustment disorder as the second most frequent

diagnosis and another mental health condition as the most frequent diagnosis.

Table 18. Diagnostic profile for children in sample ICD-10 Diagnosis Codes Description

Primary diagnosis

Secondary diagnosis

% of children % of children F30-F39 Mood disorders 9.8% 9.2% F40-F41 Anxiety disorders 2.5% 3.2% F43 Reaction to severe stress, and adjustment disorders 62.2% 12.1% F90 ADHD 13.2% 12.4% F91 Conduct disorders 9.4% 7.0%

F93-F98 Other behavioral and emotional disorders with onset usually occurring in childhood and adolescence 2.3% 3.2%

F20-F29, F42, F48, F50-F59 Other mental health disorders 0.7% 2.2% Note. Not included in the percentages are 75 children that did not have a primary mental health diagnosis in the data.

Only 206 children had an encounter where the primary or secondary diagnosis was for a

substance abuse condition. Of the 206, 159 (77.2%) were for cannabis-related disorders (ICD-10

F12). The remaining 47 children had a substance abuse diagnosis that included alcohol, opioids,

cocaine, and nicotine but each diagnostic category had less than 10 children. Of course, it is

important to note that a diagnosis indicates meeting the criteria for abuse or dependence. The

lack of a diagnosis does not mean a lack of substance use. In addition, the low prevalence rate

likely reflects the young age of children in the sample.

Child Characteristics and Diagnoses by County. Table 19 contains child characteristics

for each county. The children in Miami-Dade County are more likely to be Black, while children

in Monroe County are more likely to be White (p<.001)16. Family structure also differs with a

16 Chi square statistics were computed to determine whether differences between Monroe and Miami-Dade Counties were statistically significant. In general, p values less than .05 are considered to be sufficient to conclude a statistically significant difference exists.

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higher proportion of households headed by single females in Miami-Dade (p<.001). Rates of

domestic violence were higher in Miami-Dade County (p=002), as were rates of absence of care

(p=.033). Rates of parental substance abuse were higher in Monroe County (p=.029).17

Table 19. Final Sample Characteristics by County Miami-Dade Monroe

n %/Mean n %/Mean

Age 3,125 9.0 132 9.7

Child gender Female 1,601 51.2 67 50.8 Male 1,524 48.8 65 49.2

Child race Black 1,752 56.1 25 18.9 White 1,254 40.1 98 74.2 Other 119 3.8 <10 6.9

Family Structure Married Couple 330 10.6 19 14.4 Single Female 1,685 53.3 54 40.9 Single Male 157 5.0 12 9.1 Unmarried Couple 681 21.8 25 19.0 Unable to determine 272 8.7 22 16.7

Type of Maltreatment

Sexual abuse 156 5.0 <10 -- Physical abuse 445 14.2 11 8.3 Neglect 1,121 35.9 47 35.6 Absence of care 1,335 42.7 44 33.3 Domestic violence 461 14.8 <10 -- Substance abuse problems 864 27.7 48 36.4

Table 20 contains the diagnostic profile for Miami-Dade and Monroe counties. The

profiles included more categories for Miami-Dade County due to the much larger sample size.

17 The rate of parental substance abuse denotes the reason for child welfare service was reported as parental substance abuse. This will be an underestimate of the number of parents with substance abuse as parents with substance abuse may enter the child welfare system for other reasons such as neglect.

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For Monroe County, the number of children with anxiety disorders, conduct disorders, and other

behavioral and emotional disorders was small and these diagnoses were aggregated into an

‘other’ category. Similar proportions of children were diagnosed with mood disorders, reaction

to stress or adjustment disorder, and attention deficit hyperactivity disorder (ADHD) in Monroe

and Miami-Dade Counties.

Table 20. Diagnostic Profile by County

Miami-Dade Monroe

ICD-10 Diagnosis Codes Description Primary diagnosis

Secondary diagnosis

Primary diagnosis

Secondary diagnosis

% of children

% of children

% of children

% of children

F30-F39 Mood disorders 9.4% 8.9% 9.1% 8.3%

F40-F41 Anxiety disorders 2.4% 3.1% -- --

F43 Reaction to severe stress, and adjustment disorders 59.8% 11.9% 65.9%

-- F90 ADHD 12.6% 11.8% 18.2% 6.1%

F91 Conduct disorders 9.2% 6.8% -- --

F93-F98

Other behavioral and emotional disorders with onset usually occurring in childhood and adolescence

2.3% 3.2% -- --

Other Other mental health disorders 4.2% 2.4% 6.8% 27.2%

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Behavioral health services. Results reported in this section include the number of

children receiving different types of behavioral health services, the number of behavioral health

service encounters, total expenditures on behavioral health services as well as expenditures per

user, and differences in service utilization and expenditures by child characteristics. Throughout

the remainder of the analysis, reported behavioral health services and expenditures include all

behavioral health services received while the child was receiving child welfare out-of-home care

in SFY 2016-2018.18

Number of children and service encounters19 by type of behavioral health service. Table

21 contains the number of children receiving different behavioral health services. Throughout

the discussion of services, the much larger sample size for Miami-Dade allowed for greater detail

in reporting of services. All 132 children in Monroe County received assessment services during

out-of-home child welfare services. Eighty-seven percent of children received at least one

outpatient behavioral health service and 72 (54.5%) received at least one medical service that

had a primary behavioral health diagnosis. Despite only 12 (9.0% of the 132 children) children

receiving residential treatment services, residential services accounted for $671,329 in

expenditures representing 53.2% of all expenditures.

In Miami-Dade County, 2,876 children (92.0% of the 3,125 children) received at least

one assessment service, while 2,183 (69.8%) received at least one service in-home or on-site and

2,266 (72.5%) received at least one outpatient service. Similar to Monroe County, 7.7% of

18 In other words, the child is the unit of observation and the time frame for examining services received by a child varies between one month and 36 months. 19 This analysis reports the number of claims/encounters in the data, which represents an approximation of the number of services. For example, a youth with a SIPP stay will typically have one record per day in SAMHIS, and one record per week (or month) in Medicaid data. In addition, some services (particularly residential services) may be partly paid by Medicaid and partly paid through SAMH funding. Thus, there may be records in multiple systems for a given service. .

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children in Miami-Dade County received residential treatment services. Despite being a small

proportion of children, residential services accounted for $12,804,558 in expenditures or 35.3%

of all expenditures on behavioral health services.

The Medicaid program funded the majority of services, 87% of total expenditures in

Miami-Dade County and 82% of expenditures in Monroe County. Our Kids paid for 11.4% of

all expenditures in Miami-Dade County and 6.7% of total expenditures in Monroe County.

SAMH funding accounted for the remaining 1.5% of expenditures in Miami-Dade and 10.9% in

Monroe County.

Table 21. Number of Children Receiving Behavioral Health Services and Number of Encounters by Service

Monroe County Number of children Number of encounters Expenditures Assessment 132 579 93,676 Inpatient 12 113 44,874 Medical 72 709 24,496 Outpatient 115 5,107 296,826 Residential 12 1,348 671,329 Targeted Case Management (TCM) 42 788 32,613 Medicaid Pharmacy 48 713 42,129 Other <10 22 55,022 Total 132 9,379 1,260,967 Miami-Dade County Number of children Number of encounters Expenditures Assessment 2,876 12,563 1,740,488 Case Management 711 21,256 1,234,302 Crisis Stabilization 226 844 169,947 Crisis Support/Emergency 30 75 2,143 In-Home and On-Site Services Overlay 2,183 76,658 8,147,403 Inpatient 388 2,747 2,762,273 Intervention 170 2,023 69,247 Medical 1,270 7,448 362,165 Outpatient-Individual 2,266 41,440 3,838,648

Prevention 57 132 29,580

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Residential 240 53,182 12,804,558

Respite Services 156 517 1,855,816 Substance Abuse Detoxification 33 208 45,749

Incidental Expenses 49 148 134,427 Outpatient-Group 227 23,165 840,721 MH Comprehensive-Individual 81 1,038 478,050

Medicaid Pharmacy 799 12,057 364,253

Other 896 16,589 836,264

Alternative Therapy 117 2,052 516,289

Total 3,125 274,142 36,232,324 Notes. Residential treatment services includes Residential Treatment Centers, Statewide Psychiatric Inpatient Program (SIPP), Specialized Therapeutic Foster Care (STFC), Specialized Therapeutic Group Home (STGH) services.

Expenditures per user. While total expenditures give an idea of the scope of services

provided to all children, Table 22 contains average expenditures per user of a service and

average expenditures per child. In other words, the first column reports the average only for

children that received that particular service, while the second column reports average

expenditures across all children in samples (132 in Monroe County and 3,125 in Miami-Dade

County). Residential treatment services are by far the most costly, with average expenditures per

user of $55,944 in Monroe County and $53,352 in Miami-Dade County. Average expenditures

for outpatient services were $2,248 per child in out-of-home care in Monroe County, while in-

home and on-site services averaged $2,607 per child and individual outpatient services averaged

$1,228 per child in Miami-Dade County. Overall, average expenditures in Monroe County per

child that received behavioral health services were $9,552. Average expenditures in Miami-

Dade County per child that received behavioral health services were $11,594.

Table 22. Expenditures per user of service and per child

Monroe County (n=132) Expenditures per user of service Expenditures per user of behavioral

health services Assessment 710 710 Inpatient 3,740 340

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Medical 340 186 Outpatient 2,581 2,248 Residential 55,944 5,086 Targeted Case Management (TCM) 776 247 Medicaid Pharmacy 877 319 Other -- 416 Total 9,552 9,552 Miami-Dade County (n=3,125) Assessment 605 557 Case Management 1,736 395 Crisis Stabilization 752 54 Crisis Support/Emergency 71 1 In-Home and On-Site Services Overlay 3,732 2,607 Inpatient 7,119 884 Intervention 407 22 Medical 285 116 Outpatient-Individual 1,694 1,228 Prevention 519 9 Residential 53,352 4,097 Respite Services 11,896 594 Substance Abuse Detoxification 1,386 15 Incidental expenses 2,743 43 Outpatient-Group 3,703 269 MH Comprehensive-Individual 5,901 153 Medicaid Pharmacy 456 117 Other 933 267 Alt therapy 4,412 165 Total 11,594 11,594

Behavioral health expenditures by child characteristics. Table 23 contains the average

expenditures by child characteristics. Behavioral health service expenditures were higher for

older children. In Miami-Dade County, expenditures were slightly higher for boys than girls,

and were slightly higher for White than Black children. Expenditures were higher when the

child was a victim of sexual or physical abuse and were lower when there was domestic violence

or substance abuse in the household. Patterns were more challenging to interpret in Monroe

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County due to the much smaller sample size, averages can be influenced by outliers. For

example, the much higher expenditures for boys ($12,666 versus $6,532 for girls) likely reflects

a more frequent use of higher cost residential services (e.g., SIPP or STGH). With relatively few

people in each cell, one or two people using higher cost residential services can have a notable

impact on average expenditures.

Table 23. Average Expenditures by Child Characteristics Miami-Dade Monroe

Number of children Average expenditures Number of children Average expenditures Age

0-5 1,025 6,432 32 3,380 6-12 1,247 12,267 63 8,479 13+ 853 16,813 37 16,720 Child gender

Female 1,602 11,047 67 6,532 Male 1,523 12,619 65 12,666 Child race

Black 1,750 10,849 25 4,002 White 1,254 12,234 98 11,528 Other 121 12,448 <10 3,462 Family structure

Married Couple 330 10,143 18 12,238 Single Female 1,680 11,597 54 7,391 Single Male 157 17,166 12 30,212 Unmarried Couple 681 9,813 26 5,253 Unable to determine 277 14,525 22 6,398 Type of maltreatment

Sexual abuse 157 15,889 <10 6,575 Physical abuse 443 15,959 11 30,159 Neglect 1,121 12,875 46 5,498 Absence of care 1,356 11,184 44 14,021 Domestic violence 459 8,493 <10 1,221 Substance abuse problems 855 6,460 47 2,849

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Differences in average expenditures between Miami-Dade and Monroe Counties can

result from a combination of price and quantity. The cost of providing a service may differ

between Miami-Dade and Monroe and thus differences in expenditures may encompass a price

differential as well as a quantity difference. Table 24 shows the average expenditures reported

for all services except residential services. In addition, the average number of encounters per

child are reported to compare quantities of services between counties and across child

characteristics.

The number of behavioral health services and average expenditures increase with age. In

Miami-Dade the average increased from 52 encounters per child ages 0 to 5 to 91 for children

ages 13 and above. The increase was less dramatic in Monroe County, from 57 per child ages 0

to 5 to 70 for children ages 13 and above. While the average number of encounters did not

increase as dramatically, average expenditures increased by 87% (6,353/3,380) in Monroe

County when comparing the 0 to 5 age group with the 13 and above age group and 67%

(9,635/5,777) in Miami-Dade County.

Table 24. Average Expenditures by Child Characteristics – Non-Residential Services Miami-Dade Monroe

Number of children

Average number of encounters

Average expend ($)

Number of children


Average expend ($)

Age 0-5 1,025 52 5,777 32 57 3,380 6-12 1,247 73 7,447 63 58 3,911 13+ 853 91 9,635 37 70 6,353 Child Gender

Female 1,602 68 6,398 67 45 3,957 Male 1,523 74 8,651 65 77 4,993 Child Race Black 1,750 68 6,881 25 37 3,088 White 1,254 73 8,261 98 69 5,045 Other 121 81 8,487 <10 38 2,002

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Family Structure Married

couple 330 63 6,066 18 95 7,130

Single Female

1,680 73 7,825 54 54 3,336

Single Male

157 82 8,595 12 92 8,891

Unmarried couple

681 64 7,080 26 69 4,414

Unable to determine

277 75 7,612 22 24 2,714

Type of Maltreatment Sexual abuse

157 101 10,527 <10 92 6,575

Physical abuse

443 88 10,193 11 93 6,899

Neglect 1,121 77 8,303 46 81 5,056 Absence of

care 1,356 71 7,506 44 58 5,041

Domestic violence

459 60 6,027 <10 16 1,221

Substance abuse

855 51 4,772 47 52 2,849

Behavioral health services and expenditures by diagnosis. Average behavioral health

encounters and expenditures are reported by diagnosis in Table 25. Expenditures while in child

welfare out-of-home care averaged $31,698 for the 295 children with mood disorders in Miami-

Dade County (total expenditures of $9.4 million) and $27,711 for 12 children in Monroe County

(total expenditures of $332,527). Average expenditures for children with ADHD averaged

$23,069 in Miami-Dade County (n=394, total expenditures $9 million) and $13,905 for 24

children in Monroe County (total expenditures of $333,708).

The presence of multiple mental health diagnoses also has implications for service needs

and expenditures. Among children in Miami-Dade County, average expenditures are $19,205

for children with multiple diagnoses compared to $4,560 for children with one diagnosis. The

difference is even larger in Monroe County with average expenditures of $19,925 for children

with multiple diagnoses and $2,144 for children with one diagnosis.

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Table 25. Behavioral Health Expenditures by Diagnosis

Miami-Dade County Monroe County

Number of children


Average exp ($)

Total expenditure

s

Number of

children


Average exp ($)

Total expenditu

res Primary Mental Health Diagnosis

Mood disorders 295 167 31,698 9,350,899 12 125 27,711 332,527

Anxiety disorders 76 70 9,448 718,015 Reaction to severe stress, and adjustment disorders 1,868 61 5,918 11,055,207 87 48 4,589 399,257

ADHD 394 160 23,069 9,089,261 24 117 13,905 333,708

Conduct disorders 289 105 14,137 4,085,452 Other behavioral and emotional disorders with onset usually occurring in childhood and adolescence 72 61 9,043 651,066 Other mental health disorders 131 61 10,018 1,312,423 <10 97 21,720 195,476

Secondary Mental health Diagnosis No 1,622 45 4,560 7,396,515 77 28 2,144 165,120

Yes 1,503 135 19,205 28,865,809 55 131 19,925 1,095,848

Mood disorders 278 158 32,007 8,897,822 11 98 21,887 240,762

Anxiety disorders 96 97 8,648 830,166 Reaction to severe stress and adjustment disorders 371 111 14,553 5,399,219 <10 79 28,033 224,268

ADHD 370 132 16,265 6,018,205 Conduct disorders 213 139 16,772 3,572,450 Other mental health disorders 101 118 15,307 1,546,031 36 152 17,523 630,818

Other 74 233 35,161 2,601,916 Substance Abuse Diagnosis No 2922 81 9,402 27,473,484 126 70 9,588 1,208,098 Yes 203 202 43,295 8,788,840 <10 102 8,812 52,870

Finally, the presence of a substance abuse diagnosis also has implications for average

expenditures. Among children in Miami-Dade County, average expenditures were $43,295 for

children with a substance abuse diagnosis compared to $9,402 for children without a substance

abuse diagnosis. Interestingly, in Monroe County, expenditures were lower for children with a

substance abuse diagnosis compared to children without a substance abuse diagnosis ($8,812

compared to $9,588), although the number of children with a substance abuse diagnosis was

quite small. The results in both counties are rather unexpected. The high costs in Miami-Dade

County are unexpectedly large because the diagnosis for most youth involved cannabis use. The

results in Monroe are unexpectedly small because regardless of the drug we would expect

substance abuse to increase the services provided to a child.

Behavioral health services and expenditures by year in child welfare. Behavioral health

services were examined for all children receiving out-of-home care in calendar years 2016-2018

in Miami-Dade and Monroe Counties. Some children entered out-of-home care in 2016-2018,

while others entered out-of-home care prior to 2016. Thus, some children were observed in their

first years of out-of-home care while others may have been in the tenth year of out-of-home care.

Average expenditures by year in child welfare service are reported in Table 26. For example, a

child entering out-of-home care on January 1st, 2016 and remaining in out-of-home care

throughout the sample time frame would have data in year 1, year 2, and year 3. Average

expenditures increased the longer a child was in out-of-home care. This reflects the relationship

between the severity of mental health conditions and the duration of out-of-home services. As

children with less severe conditions achieved permanency, the remaining children had higher

severity conditions and thus had high average expenditures.

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Table 26. Behavioral Health Expenditures by Year of Child Welfare Miami-Dade County Monroe County Year in child welfare out-of-home care

Number of children

Number of encounters

Average exp ($)

Number of children


Average exp ($)

1 2,556 40 4,906 111 39 5,316 2 1,637 45 5,535 65 41 4,362 3 836 48 7,174 25 55 8,060 4+ 486 121 17,764 20 52 9,290

Behavioral health services and expenditures by placement in child welfare. Table 27

reports average encounters and expenditures for children based on placement. Once again, due

to the larger sample size, greater detail was reported for Miami-Dade County. Average

expenditures were highest when the initial placement was in a psychiatric hospital or residential

treatment center, and lowest when the youth was placed with a relative.

Table 27. Behavioral Health Expenditures by Placement Type Miami-Dade Monroe

Children Number of encounters

Average expenditures ($) Children


Average expenditures ($)

Foster Home - Non-Relative 926 106 14,307 42 60 5,236 Residential Treatment Center 26 114 29,060 -- Correctional Placement 30 86 17,653 -- Non-Relative 252 53 5,727 -- Relative 1,035 49 5,209 37 49 2,352 Residential 746 116 14,379 40 103 18,969 Hospitalization Medical 43 65 10,402 -- Hospitalization Mental 56 225 57,336 -- Other 11 348 42,212 13 72 15,080 Note. For Miami-Dade County, other includes adoption placements and licensed care –other due to small sample sizes in each. For Monroe County, other includes adoption, licensed care-other, residential treatment center, correctional, non-relative, and hospitalization for medical or mental health care.

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The preceding tables have examined average behavioral health expenditures across child

characteristics, diagnoses, and the time in child welfare out-of-home placements. However, it

remains difficult to draw conclusions based on averages. Thus, the standard approach is to

perform a regression analysis that enables isolation of marginal effects while controlling for

other characteristics.

Regression results. Table 28 contains the regression results that examine the

determinants of behavioral health expenditures. The first set of results examined a full model

while the second set of results examined a parsimonious model that focused only on statistically

significant effects.

The results suggest that relatively few factors are the primary determinants of behavioral

health expenditures. Children ages 6-12 have higher expenditures than children ages 13 and

above. Children in households with parental substance abuse receive fewer services than

children in households without identified parental substance abuse. The longer children receive

out-of-home care, the higher their behavioral health expenditures. Once again, this is unlikely a

causal relationship, and most likely reflects the greater severity of behavioral health problems

among children that do not achieve permanency. Behavioral health diagnoses are an important

determinant of expenditures. Children with mood disorders and ADHD tend to have the highest

expenditures. Children that have multiple mental health diagnoses have significantly higher

expenditures than children with a single mental health diagnosis. Children with substance abuse

disorders have average expenditures over $24,000 higher than children without substance abuse

disorders.

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Table 28. Regression Results: Determinants of Behavioral Health Expenditures Full Model Parsimonious Model Coef Std error p value Coef Std error p value Intercept -15551 3518 <.0001 -13658 1747 <.0001 Age (ref: age 13+) 0-5 2658 1611 0.0990 2244 1563 0.1512 6-12 4492 1456 0.0021 4311 1431 0.0026 Family Structure (ref: unmarried couple) Single Female -452 1337 0.7351 Single Male 2939 2575 0.2538 Married Couple -1226 1960 0.5316 Unable to determine 878 2065 0.6705 Gender (ref: male) Female -1093 1069 0.3066 Race (ref: White) Black -2241 1102 0.0422 Other -744 2742 0.7861 Type of Maltreatment Physical abuse 3146 1799 0.0804 DV -489 1536 0.7501 Sexual abuse 4350 2607 0.0954 Caregiver unavailable 831 1376 0.5462 Neglect 1024 1192 0.3905 Parental substance abuse -2688 1431 0.0623 -3485 1181 0.0032 County (ref: Monroe County) Miami-Dade County 2201 2668 0.4094 Year in child welfare Year in child welfare 6780 533 <.0001 6792 527 <.0001 Diagnosis (ref: acute reaction to stress and adjustment disorders F43)

Mood disorders (F30-F39) 12235 2010 <.0001 12011 2000 <.0001 Anxiety disorders (F40-F41) -1957 3456 0.5712 -1797 3447 0.6022 ADHD (F90) 8624 1662 <.0001 8799 1641 <.0001 Conduct disorder (F91) -2574 1948 0.1865 -2820 1930 0.1441 Other behavioral and emotional disorders with onset usually occurring in childhood and adolescence (F93) -1182 3626 0.7443 -1173 3620 0.7457 Other mental health disorder 6103 3099 0.0490 5904 3085 0.0558 Secondary Mental Health and Substance Abuse Diagnoses

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Secondary mental health diagnosis 7848 1145 <.0001 8049 1141 <.0001 Substance abuse diagnosis 24508 2368 <.0001 24682 2361 <.0001 Placement (ref: relative)

Foster home – non-relative 2587 1364 0.0581 2462 1346 0.0674 Residential treatment center 10899 6061 0.0722 11201 6035 0.0636 Correctional placement -3448 5568 0.5358 -3340 5549 0.5472 Non-relative -574 2046 0.7790 -785 2039 0.7001 Residential 2460 1475 0.0957 2245 1452 0.1223 Hospitalization – Medical 5727 4659 0.2191 5531 4644 0.2337 Hospitalization - Mental 34874 4067 <.0001 34481 4046 <.0001 Other 31179 10458 0.0029 30995 10428 0.0030 R squared 0.2143 0.2107 Number of children 3257 3257

Medicaid plan enrollment and service utilization. The Medicaid Statewide Medicaid

Managed Care (SMMC) program includes standard Medicaid Medical Assistance (MMA) plans

as well as specialty plans for children in child welfare, children’s medical services (CMS),

Medicaid recipients with serious mental illness, and HIV/AIDS. The specialty plan for children

in the child welfare system (CWSP) is currently managed by Sunshine Health. All children with

an open child welfare case become eligible for Medicaid and the CWSP upon their entry into the

child welfare system. Recipients may select a MMA plan other than the CSWP, however, those

who do not select a plan are automatically enrolled in the Sunshine CWSP. (For a more detailed

description of the CWSP and enrollment information, see

https://ahca.myflorida.com/medicaid/statewide_mc/pdf/mma/Specialty_Plans_110316.pdf).

Many children are enrolled in the Medicaid program prior to entering child

welfare services. Assignment to the Sunshine CWSP is automatic for children/parents

that did not select their MMA plan. However, assignment is not automatic when the

child/parent selected the MMA plan.

https://ahca.myflorida.com/medicaid/statewide_mc/pdf/mma/Specialty_Plans_110316.pdf

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This section of the report examines enrollment patterns in the months following

entry into out-of-home care as well as service utilization patterns in those months. The

analysis is limited to the 2,038 children that entered out-of-home care in CY 2016-2018.

Table 28 provides enrollment patterns in the month of removal as well as the following

three months. Most children were enrolled in standard MMA plans in the month that

they entered out-of-home care. Prior to entering out-of-home care, most children would

not have been eligible for a specialty plan and thus would have been enrolled in a

standard MMA plan. At some point in that month, when the child enters out-of-home

care, they become eligible for the specialty plan. However, the process of transitioning to

the Sunshine specialty plan takes time. The median length of time between entering out-

of-home care and the start of enrollment in the specialty plan was 45 days.

Approximately 24% of children were enrolled in the specialty plan in the month after

entering out-of-home care. This percentage increased to 66% in the second month and

74% in the third month.

Table 29 also looks at utilization patterns during the first few months. The table

includes all expenditures regardless of the funding source. In other words, service

utilization includes services paid by Our Kids, DCF Substance Abuse and Mental Health,

and Medicaid (including Medicaid fee-for-service, and all MMA plans including the

specialty plan). The percentage of children receiving any behavioral service does not

differ much between children in the specialty plan and children in standard MMA plans.

The highest percentages are in the month after entering out-of-home care when many

children would be receiving their Comprehensive Behavioral Health Assessment

(CBHA). However, differences between the specialty plan and standard MMA plans are

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observed for the number of services provided and service expenditures. Among children

receiving any behavioral health services in that month, children in the Sunshine Specialty

plan tended to receive more services than children enrolled in standard MMA plans. In

addition, expenditures were higher for children in the specialty plan.

Table 29. Service Penetration and Utilization by Month and Medicaid Plan Month of removal Month after removal 2 months after 3 months after

Sunshine CW Plan

Other MMA Plan

Sunshine CW Plan

Other MMA Plan

Sunshine CW Plan

Other MMA Plan

Sunshine CW Plan

Other MMA Plan

Children 160 1,875 488 1,535 1,355 674 1,480 532

Received Any BH service

# that received any BH service 77 596 381 1,231 851 405 908 315

% that received any BH service 48% 32% 78% 79% 63% 61% 61% 59%

Number of services

Mean among users 4.66 2.37 5.17 2.99 6.02 4.46 6.17 4.70 Median among users 3 1 3 2 4 3 4 3

Expenditures

Mean among users 592 495 988 671 698 523 727 624 Median among users 233 233 727 630 317 147 293 159

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Differences in service use and expenditures can be driven by a few high utilizers of

expensive residential services. Table 30 reexamines the utilization of services, limiting services

to those considered to be non-residential children’s services (see

https://www.myflfamilies.com/service-programs/samh/samhis/155-2-v10/c11v10.pdf for a list

of cost centers defined as non-residential children’s services).20 A very similar pattern is

observed, with small differences in the proportion of children receiving services, and more

substantive differences in the number of expenditures and average expenditures among children

receiving services.

Table 30. Non-residential Service Penetration and Utilization by Month and Medicaid Plan Month of removal Month after removal 2 months after 3 months after

Sunshine CW Plan

Other MMA Plan

Sunshine CW Plan

Other MMA Plan

Sunshine CW Plan

Other MMA Plan

Sunshine CW Plan

Other MMA Plan

Children 160 1875 488 1,535 1,355 674 1,480 532

Community Services

# that received any BH service 73 522 372 1,211 840 386 874 307

% that received any BH service 46% 28% 77% 78% 62% 57% 59% 58%

Number of services

Mean among users 3.75 2.06 4.16 2.61 5.01 4.04 5.05 4.33 Median among users 3 1 3 1 4 3 4 3

Expenditures

Mean among users 457 393 852 595 538 388 483 312 Median among users 226 160 727 630 311 147 293 146

20 Children’s non-residential services include: Assessment, Case Management, Day/Night, In-Home/On-Site, Intensive Case Management, Intervention, Medical Services, Outpatient (Individual & Group), Respite Services, Supported Employment, Supported Housing/Living, Incidental Expenses, Aftercare/Follow-up, Information and Referral, BHOS, Aftercare – Group, Intervention Group.

https://www.myflfamilies.com/service-programs/samh/samhis/155-2-v10/c11v10.pdf

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Table 31 contains the same statistics for residential services. While based on a much

smaller number of children that use services, the pattern of a higher number of services for

children in the specialty plan was also found for residential services. No clear pattern was found

for expenditures, which can easily be driven by one or two outliers.

Table 31. Inpatient/Residential Service Penetration and Utilization by Month and Medicaid Plan

Month of removal Month after removal 2 months after 3 months after

Sunshine CW Plan

Other MMA Plan

Sunshine CW Plan

Other MMA Plan

Sunshine CW Plan

Other MMA Plan

Sunshine CW Plan

Other MMA Plan

Children 160 1,875 488 1,535 1,355 674 1,480 532

Inpatient/Residential/Crisis Services

# that received any BH service 5 37 17 44 39 22 49 16

% that received any BH service 3.13% 1.97% 3.50% 2.80% 2.90% 3.50% 3.30% 3.00%

Number of services

Mean among users 12 3.43 18.23 4.34 14.33 3.13 14.36 2.56 Median among users 6 2 22 2 4 1 5 2

Expenditures

Mean among users 1,076 1,986 3,197 3,226 2,476 388 4,158 5,211 Median among users 815 311 3,667 2,916 910 147 4,074 2,917

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Service utilization based on children’s needs. As described previously, records were

reviewed for a sample of 165 children to identify service needs. Children were placed in groups

based on the findings of this review and the service recommendations in the child’s record. Five

groups were identified: children with no service recommendations, children with one

recommended service, children with two recommended services, children with 3 or more

services recommended, and children with a higher level of care need (e.g., residential treatment).

Given that behavioral health services were only examined in CY 2016-2018, we

restricted the sample to the 101 children who entered out-of-home care in CY 2016-2018 for

whom we were able to gather data on service recommendations. The remaining 64 children

either entered out-of-home care prior to January 1, 2016 or did not have clear service

recommendations. Data are presented by level of service recommendations. Sample size

considerations prevent looking at more refined groupings (e.g., a combination of age and service

recommendations).

Table 32 contains the number of children by level of recommended service, the

percentage of children that received any behavioral health service, and average per child

expenditures (represents total expenditures during the out-of-home episode). For each level of

need, all children received at least one behavioral health service. Expenditures increased as the

level of need increased.

Table 32. Percentage of children that received any behavioral health service and average expenditures

Number of children Users of services % Mean $ Median $ No services recommended 12 12 100.0% 1,567 715 1 service recommended 29 29 100.0% 2,929 1,657 2 services recommended 33 33 100.0% 3,180 2,672 3+ services or TBOS 24 24 100.0% 16,969 5,870 High level of need 3 3 100.0% 31,244 11,049

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In Table 33, service utilization was examined by level of need. Services are classified as

assessment, non-residential, residential, and other (includes medications, lab services, durable

medical equipment, and transportation services). With the exception of one child with a high

level of need, all children received at least one assessment service. Most children received non-

residential services; although 4 children with one recommended service, 1 child with 2

recommended services, and 1 child with 3+ recommended services did not receive any non-

residential services. Among children without a higher level of need, non-residential services

were received by most children; children with greater needs received more services. Among the

three children with a higher level of need, only one received any residential services. In

addition, while the average expenditures for non-residential services were quite high for children

with a higher level of need, most of these costs were for in-home respite services and not direct

behavioral health treatment.

Table 33. Service utilization by level of service need Assessments Non-residential Residential Other

Number of Children

Cost per child

Number of children

Cost per child

Number of children

Cost per child

Number of children

Cost per child

No services recommended (n=12) 12 600 5 2,200 1 325 3 91 1 service recommended (n=29) 29 667 28 1,978 0 0 11 925 2 services recommended (n=33) 33 629 32 2,614 0 0 10 51 3+ services or TBOS (n=24) 24 780 23 8,076 8 19,294 12 4034 High level of need (n=3) 2 1,607 3 7,251 1 64,797 2 1,982

Evidence on the time until treatment is provided in Table 34. The mean and median

length of time between the date of entry into out-of-home care and the assessment date reported

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in the claim/encounter is reported. The median number days suggests that most children

received their assessment within 30 days. However, the mean number of days is larger than the

median, suggesting that some children have much longer waits before receiving services. One

caveat is that we cannot determine whether a provider used a non-assessment procedure code

when submitting the encounter. There is a possibility that some youth with longer wait times

had received a prompt initial assessment, and the data are capturing a follow-up assessment.

Table 34. Number of days until assessment Children Children with assessments Mean days Median days

No services recommended 12 12 112 30 1 service recommended 29 29 25 25 2 services recommended 33 33 47 30 3+ services or TBOS 24 24 60 27 High level of need 3 2 20 20

Another perspective is to examine the length of time between entering out-of-home care

and the data of the first service received by the child. Interestingly, many children received

behavioral health services before the assessment was completed (or at least the date reported on

the encounter). The median number of days ranged from 15 (higher level of need) to 29 (no

recommended services, 2 recommended services).

Table 35. Number of days until first non-assessment service

Children Children with non-assessment

services Mean days Median days No services recommended 12 12 50 29 1 service recommended 29 29 20 23 2 services recommended 33 33 36 29 3+ services or TBOS 24 24 36 26 High level of need 3 2 15 15

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Table 35 examined the length of time until the child received their first non-assessment

service. However, evidence-based practices typically require regular therapeutic services. In

Table 36, we report the median number of days between the first ten non-assessment services.

As reported above, the median number of days before the first non-assessment service ranged

from 15-29 days across the levels of need. After the first 2-3 services, the median time between

services stabilized at one week. Thus, the number of days between services are consistent with

many evidence-based therapeutic services. The greater concern might be the number of services

some children received. For example, across the levels of need, the number of children started to

decline after only three services. Eleven of the 29 youth with one recommended service have

less than 10 service encounters. Similarly, 9 of the 33 children with two service

recommendations received less than 10 service encounters. However, firm conclusions cannot

be drawn. Treatment for adjustment disorders without trauma tends to be brief, and thus it is

conceivable that some children will only need limited therapeutic services.

Table 36. Number of days between services 1 service recommended 2 services recommended 3+ services or TBOS High level of need

Service Number of

children Median Number of



children Median 2 24 12 31 15 23 8 3 12 3 24 12 31 11 23 7 3 7 4 22 9 30 7 23 7 3 14 5 22 7 29 7 23 8 3 5 6 21 6 28 7 22 7 3 7 7 19 7 27 7 21 7 3 5 8 19 7 26 7 20 7 2 4 9 18 7 26 7 20 7 2 9

10 18 6 24 7 19 7 2 7 Number of children 29 33 24 3

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Discussion

Children who enter the foster care system often have complex needs and require

behavioral health services. It is therefore critical that child welfare systems have procedures in

place to ensure timely assessment of children’s behavioral health needs, identification of

appropriate services, cohesive coordination of care across agencies, and ongoing monitoring to

ensure children’s needs are met. Findings from this study indicate that the Department of

Children and Families, Sunshine Health, and Citrus Family Care Network have established

policies around how behavioral health needs should be assessed and how services should be

coordinated for children in licensed foster care, and that a large network of behavioral health

providers has been established to serve this population. There were, however, a number of gaps

identified that present barriers to children in licensed care receiving the services they need.

First, several concerns and discrepancies emerged with regard to assessment processes.

According to policy, all children who enter out-of-home care should be referred for a

Comprehensive Behavioral Health Assessment (CBHA) within seven business days of their

removal, assessments should be scheduled by providers within 72 hours of receipt of the referral,

and children should subsequently be connected to the services recommended in the CBHA

within 30 days of the assessment. Findings suggest that at times there are delays in this process.

Case managers reported that they encounter wait lists for getting assessments, and providers

confirmed that children may wait up to three weeks to receive a CBHA. This results in delays to

service planning and referrals, as case managers are largely dependent on the provider

recommendations.

There were also some concerns with regard to the quality of assessments, and particularly

the recommendations provided. Some case managers questioned how accurate and

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comprehensive the CBHAs actually were, since providers completed them fairly quickly and

having limited contact with the child (typically two hours). Providers also acknowledged that

completing a thorough assessment could be challenging if they were unable to speak with the

child’s biological parents or another knowledgeable caregiver. Thus, assessments at times must

be concluded with incomplete information.

Based on the case record reviews completed, CBHAs for the most part appeared to be

very detailed and comprehensive, however, the service recommendations were frequently

generic and rarely included recommendations for specific treatment modalities or evidence-based

treatments specific to the child’s particular needs. This was also reported as a challenge by case

managers, who depended on the CBHA to identify service needs, but found that the

recommendations provided were not specific enough and overwhelmingly recommended the

same basic set of services – individual therapy and psychiatric services. Furthermore,

recommendations for trauma-based therapeutic interventions were rare, despite the fact that

children in out-of-home care likely have incurred one or more traumatic experiences. While

17.6% of the children whose cases were reviewed were diagnosed with a trauma-related

disorder, only 10.3% were recommended for trauma-based treatment, and even fewer had a

recommendation for a specific evidence-based trauma intervention. Another disjuncture was

observed between the number of children diagnosed with a substance use disorder (n = 8) and the

number of children who received a recommendation for substance abuse treatment (n = 3).

Another identified gap, according to providers, was that children’s needs and services

were often approached from a child-focused rather than family-focused perspective. This

approach fails to understand the child’s needs within the context of the family, the ways in which

family dynamics contribute to the child’s needs, and the importance of involving the family in

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the child’s treatment. Case review findings found that fewer than one-third of children (31.5%)

were referred for family therapy, compared to 39% who were rated as having needs pertaining to

family relationships on the FFA-O. This may be an opportunity for improvement when service

recommendations are made in CBHAs and other mental health assessments to incorporate more

family therapy and family engagement in the child’s treatment.

Additionally, there were some discrepancies found between case manager and behavioral

health assessments of children’s needs in the case record reviews. Although the CBHAs that

were reviewed tended to be detailed and thorough, these assessments are completed when a child

first enters care, whereas mental health functioning and needs might become more evident or

exacerbated over time. Case managers have greater contact with children over an extended

period of time compared to mental health assessors, and therefore have greater opportunity to

identify needs. With regard to case managers, specifically, concern was expressed that workers

lack adequate knowledge and training on behavioral health assessments and treatment options.

While case managers were not expected to be experts in mental health, respondents expressed

that it was important for them to at least have some working knowledge of children’s mental

health issues and the evidence base for various treatment services, since they are the ones tasked

with following up on assessment recommendations and making service referrals. Enhanced

communication and coordination between child welfare and behavioral health providers would

help to improve consistency in assessments and facilitate identification of need.

Study findings indicate strong agreement overall about the need for greater cohesion,

communication, cooperation, and coordination across agencies and systems. This area of

identified need extended from the initial assessment process through the coordination of care for

children. A need for more frequent communication and information sharing, both between

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providers and across various system partners (e.g. case managers, GALs, attorneys, therapists,

and caregivers) was emphasized by providers. Case managers similarly reported that some of

the greatest challenges they faced in coordinating care were a lack of engagement and

cooperation from foster parents, lack of communication from providers, and expectations that

case managers transport children to and from appointments. Providers also emphasized a need

for cross-system training on trauma and children’s behavioral health. A more coordinated

approach to service provision, with various agencies working together as partners for the best

interest of the child, emerged as a clear need. While policies set by DCF, Sunshine Health, and

CFCN discuss coordination of care, a need for clearer guidelines on these processes and how

various agencies should work together was evident.

Respondents also expressed a need for greater inclusion of the family, either biological

and/or foster caregivers, in children’s mental health treatment and care coordination. Case

managers reported the lack of engagement from foster parents, particularly with regard to taking

children to appointments, was a substantial barrier. Furthermore, respondents indicated that

more comprehensive training on children’s mental and behavioral health issues for foster parents

would be beneficial, particularly training on behavior management.

Another significant gap identified through the study was with regard to the

documentation of children’s behavioral health needs and services. There were notable

discrepancies found between the review of DCF policy and the documentation contained in

FSFN. First, while the majority of children whose files were reviewed did have a completed

CBHA on file, a considerable portion of children (15%) did not, despite the requirement that

every child who enters out-of-home care receive a CBHA. For the vast majority of cases,

furthermore, CBHAs were not uploaded to FSFN, but were instead found in the Lead Agency’s

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ASK data system. The review also showed that FFAs did not consistently incorporate findings

and recommendations from the CBHA, nor was such information consistently documented in the

mental health section of FSFN. Findings indicate a strong need for consistent documentation

and the ability for tracking and notification of a child’s mental health functioning, needs,

recommended interventions, and status updates as a dynamic, ongoing, real time process

throughout a child’s involvement in child welfare. This would require enhanced coordination

between the CBC Lead Agency, case management agencies, behavioral health providers,

Sunshine Health, and DCF.

Several gaps were identified with regard to the availability and accessibility of behavioral

health services for children in licensed care. These included limited availability of specialized

and higher level of care services, especially in Monroe County, and limited availability of

services for children with serious conduct disorders, eating disorders, personality disorders,

gender or sexual identity issues, and victims of human trafficking. The utilization and

availability of specific evidence-based and trauma-informed interventions also appeared to be

limited, as was the availability of home- and school-based treatment services. Concerns about

the lack of evidence-based treatments, or limited effectiveness of available services, were

expressed by both providers and case managers. Wait lists were another commonly reported

challenge, which created delays in accessing services or in some cases resulted in children

receiving less appropriate services in an effort to provide something while they waited for the

recommended services. Limited funding and resources were also a significant barrier, which

made it difficult for providers to recruit and retain qualified staff when they were unable to

provide adequate compensation. Finally, eligibility criteria established by primary funding

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streams such as Medicaid may limit access to early intervention for children who have mild to

moderate behavioral health needs that do not yet warrant a mental health diagnosis.

Some additional potential gaps in services were also identified through the analysis of

service utilization patterns. First, Medicaid encounter/claims data did not show that all children

received assessments within a month of entering out-of-home care. This also corresponds with

the findings from the case record reviews, which also found some children lacked evidence of a

CBHA. While it is possible the findings merely reflect a lack of complete encounter data, the

Department should ensure that assessments are completed for all children entering out-of-home

care. Another identified gap was that some children with identified service needs did not receive

any non-assessment services. For example, four children with one recommended service, one

child with two recommended services, and one child with three or more recommended services

did not receive any treatment services.

The findings also suggest that children with the highest level of need may require greater

monitoring. Of three children identified with a need for a higher level of care, only one received

inpatient/residential treatment services and the majority of their non-residential costs involved

in-home respite services instead of therapeutic services. Finally, while most children with

identified needs received regular, ongoing services, some children with identified needs received

only a few services. It could not be determined whether the provided services were or were not

adequate to address the child’s needs, or what the reason was for termination of services, but the

very short duration of services for some children (e.g. less than one month) does not appear to be

in accordance with generally recognized best practice.

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Recommendations

Based on the gaps identified through this study, the following policy and practice

recommendations are offered to improve the assessment of children’s behavioral health needs,

array of children’s behavioral health services, and coordination of care for children in licensed

foster care. While the recommendations made are specific to findings for the Southern Region,

some of the recommended changes, such as those pertaining to FSFN documentation or

suggestions for monitoring treatment progress, would ideally be implemented at a statewide

level. Recommendations are as follows:

• Require an expedited process for enrollment into the Sunshine Child Welfare Specialty Plan

(CWSP) to reduce the length of the transition period. Most children entering out-of-home

care are eligible for the Medicaid program and are enrolled in either the CWSP or a standard

MMA plan. Given the rules on plan enrollment, it can take weeks if not months for a child to

be enrolled in the CWSP. One option is for an enrollment change from a standard plan to the

specialty plan to become effective immediately instead of the following month. Another

option involves making the transfer from a standard MMA plan to the specialty plan

automatic (i.e., become the default), with the option of remaining in the standard MMA

plan. Such steps would reduce the time between entering out-of-home care and enrollment in

the specialty plan.

• Since the current study only examined the policies of the Sunshine CWSP, but found that a

considerable number of children were enrolled in other MMA plans, the Department should

further explore the other plans to assess their approach to the child welfare population and

how these plans compare to the specialty plan. Expenditure data indicate that children

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enrolled in the CWSP received a greater number of services compared to children in standard

MMA plans, which could reflect differences in policies, but further study is necessary.

• The Department of Children and Families and the Agency of Health Care Administration

need to work together to develop better monitoring of children in the child welfare system.

Systems are in place to enroll a child in a Medicaid managed care plan once they have an

open case in FSFN. These same systems should be expanded to provide the Department of

Children and Families with monthly updates of encounter data received by AHCA from

managed care plans. FSFN currently does not have information on child service needs.

Variables capturing such needs should be developed and be a mandatory field in FSFN. This

would enable a matching of FSFN data with Medicaid data, and the development of

algorithms to flag children who are not receiving recommended services. This would be a

clear important step in identifying any children who do not receive prompt assessments, who

do not receive services, or whose services are not aligned with recommended needs.

• A strong reinforcement for CBC Lead Agencies and Case Management Organizations to

adhere to contract language requirements for FSFN data entry, including but not limited to

the CBHA and treatment updates.

• A policy change that allows for the CBHA information to be entered in FSFN rather than

uploaded as a PDF. This change will allow the Department, Lead Agencies, and CMOs to

use CBHA data to track outcomes and receipt of recommended services.

• A policy change that requires reassessment of children who receive a mental health diagnosis

to determine if the symptoms have improved, require ongoing treatment, or have manifested

into more serious mental health needs. All subsequent mental health assessments and

recommendations should be uploaded into FSFN.

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• The study team could not find that Sunshine Health has clinical guidelines or practice toolkits

for their providers specific to behavioral health needs of children other than for ADHD. As

possible, Sunshine Health should move toward making available practice guidelines for

Child Welfare Specialty Plan behavioral health providers specific to the behavioral health

needs and disorders found in children and specifically adjustment disorder, given its high

prevalence in the population.

• A practice change that requires behavioral health providers to use a multi-disciplinary team

approach, with team meetings at regular intervals to review cases, assess progress, and

identify new or ongoing service needs.

• A policy change to increase training on children’s mental and behavioral health issues for

foster parents, with attention to strategies for behavior management. Move toward a

philosophical shift from seeing foster homes as placements to foster parents as an essential

part of the child’s treatment intervention team.

• Expand and diversify the service array by engaging smaller community organizations, in

addition to the larger agencies. Engaging smaller organizations in the provider network

could help to fill some of the gaps or provide more individualization of services than larger

agencies are able to offer.

• Expand the service array in Monroe County, especially for higher level of care services.

• Expand the availability of services for children with serious conduct disorders, eating

disorders, personality disorders, gender or sexual identity issues, and victims of human

trafficking.

• Expand the availability of specific evidence-based and trauma-informed interventions and

expand case managers’ knowledge of the currently available services.

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• Expand eligibility criteria established by primary funding streams such as Medicaid to access

early intervention for children who have mild to moderate behavioral health needs that do not

yet warrant a mental health diagnosis.

• The Department should ensure that assessments are completed for all youth entering out-of-

home care.

• Increase the level of specificity provided in the CBHA and other assessments regarding

recommendations for specific treatment modalities or evidence-based treatments specific to

the child’s particular needs.

• Policy that looks more closely at CBHAs involving children with a substance use disorder,

ensuring that appropriate recommendations to substance abuse treatment are made.

• To enhance the well-being of the family, policies are needed that include requirements for

family therapy.

• To enhance child well-being, policies and contracts should require family involvement in

therapeutic services for the child.

• Enhanced training for child welfare frontline staff to identify behavioral health needs.

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children following maltreatment and neglect. Verhaltenstherapie, 20(1), 37-44.

Ringeisen, H., Stambaugh, L., Bose, J., Casanueva, C., Hedden, S., Avenevoli, S. … & West, J.

(2017). Measurement of childhood serious emotional disturbance: State of the science

and issues for consideration. Journal of Emotional and Behavioral Disorders, 25(4),

195–210.

Simms, M. D., Dubowitz, H., & Szilagyi, M. A. (2000). Health care needs of children in the

foster care system. Pediatrics, 106(Suppl.), 909-918.

Simms, M. D., Madelyn, F., Battistelli, E. S., & Kaufman, N. D. (2018). Delivering health and

mental health care services to children in family foster care after welfare and health care

reform. In Family Foster Care in the Next Century (pp. 167-184). Routledge.

Sullivan, D. J. & van Zyl, M. A. (2008). The well-being of children in foster care: Exploring

physical and mental health needs. Children and Youth Services Review, 30, 774-786.

http://www.nimh.nih.gov/health/statistics/mental-illness.shtml#part_154788

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Szilagyi, M. A., Rosen, D. S., Rubin, D., & Zlotnik, S. (2015). Health care issues for children

and adolescents in foster care and kinship care. Pediatrics, 136(4), e1142-e1166.

Tarren-Sweeney, M. (2017). Rates of meaningful change in the mental health of children in

long-term out-of-home care: A seven-to nine-year prospective study. Child abuse &

neglect, 72, 1-9.

Turney, K., & Wildeman, C. (2016). Mental and physical health of children in foster

care. Pediatrics, 138(5).

United States Census Bureau (2018). Quick Facts: Miami-Dade County, Florida.

www.census.gov/quickfacts/miamidadecountyflorida.

United States Census Bureau (2018b). American Fact Finder: Monroe County, Florida.

www.census.gov/quickfacts/monroecountyflorida.

http://www.census.gov/quickfacts/miamidadecountyflorida.

http://www.census.gov/quickfacts/monroecountyflorida

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Appendix A

Data Collection Protocols

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FSFN ID#____________________ Case File Review Protocol Child Welfare Case Management (FSFN) File Review

Date of Case Review _____ / ____ / _____ Reviewer Name: ___________________________

1. Case Management Agency: ___________________________

2. Date case open to out-of-home care: _____/_____/_____

3. Date case open to case management agency: _____/_____/_____

4. Date case closed to case management agency: _____/_____/_____ N/A Child’s case still open to case management agency

4. Gender of Child: Female Male 5. Child DOB: _________

6. Type of Placement: Licensed Foster Home Relative Non-Relative Residential Group Home Specialized Therapeutic Foster Home Specialized Therapeutic Group Home Statewide Inpatient Psychiatric Program (SIPP) Other ___________________________

7. Type(s) of maltreatment identified in child welfare file:

7a. ___________________________ 7c. __________________________ 7e. __________________________ 7b. ___________________________ 7d. ___________________________ 7f. ___________________________

8. Mental Health Diagnosis identified in child welfare file:

8a. ___________________________ 8b. ___________________________ 8c. ___________________________

Source of Diagnosis (if identified) N/A Diagnosis not in file

___________________________ ___________________________ ___________________________

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Child Welfare Assessments

9. Family Functioning Assessment – Investigation (FFA-I) Date completed ___ / ____ / ____

Sources of information for FFA-I:

FFA-I includes an assessment of child’s functioning: Yes No FFA-I includes an assessment of child’s needs: Yes No The description of functioning and needs is adequate to determine the child’s behavioral health needs? Yes No Reviewer’s comments:

10. Family Functioning Assessment - Ongoing (FFA-O) Date completed ___ / ____ / ____ N/A Not completed

Sources of information for FFA-O:

FFA-O includes an assessment of child’s functioning: Yes No FFA-O includes an assessment of child’s needs: Yes No The description of functioning and needs is adequate to determine the child’s behavioral health needs? Yes No Reviewer’s comments:

11. Progress Updates were completed every 90 days after approval of FFA-O, or more frequently if needed Yes No

Sources of information for Progress Updates:

Progress Updates include an updated assessment of child’s functioning: Yes No Progress Updates include an updated assessment of child’s needs: Yes No The description of functioning and needs is adequate to determine the child’s behavioral health needs? Yes No Reviewer’s comments:

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Family Functioning Assessment: Child Need Indicators

12. In the fields below document the Child Need Indicator ratings (A-D) for each category as identified on the FFA-Investigations, FFA-Ongoing and the most recent FFA Progress Update

Emot

iona

l/ Tr

aum

a

Beha

vior

al

Dev

elop

men

t

Educ

atio

n

Phys

ical

/Hea

lth

/Dis

abilit

y

Fam

ily

Rel

atio

nshi

ps

Peer

/Adu

lt R

elat

ions

hips

Cul

tura

l Ide

ntity

Subs

tanc

e Aw

aren

ess

Life

Ski

lls

Dev

elop

men

t

FFA-Investigations Date completed ___ / ____ / ____

FFA-Ongoing Date completed ___ / ____ / ____

FFA Progress Update Date completed ___ / ____ / ____

13. List the name and date of completion of all other Mental Health Related assessments of the child included in the child welfare file

Name of assessment Completed by Date of assessment:

___ / ____ / ____

___ / ____ / ____

___ / ____ / ____

___ / ____ / ____

___ / ____ / ____

___ / ____ / ____

___ / ____ / ____

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___ / ____ / ____

___ / ____ / ____

Case Planning

14. Is there evidence that Case Planning Conferences included planning for the mental health needs and appropriate services for the child? Yes No

Reviewer’s comments: 15. Does the file contain evidence that the Case Planning Conferences resulted in recommendations and referrals for the child to receive appropriate mental health services?

Yes No Reviewer’s comments: 16. Is there evidence that follow up was conducted by case management to ensure that the child was receiving the recommended mental health services?

Yes No Reviewer’s comments:

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Stakeholder Interview Protocol The purpose of this interview is to obtain information about the behavioral health services provided to children in licensed foster care in the Southern Region of Florida (Miami-Dade and Monroe Counties). We are collecting this data as part of the Southern Region Behavioral Health Services Capacity and Gap Analysis Study, which is being conducted by the University of South Florida at the request of the Department of Children and Families. You are being asked to take part in this interview because of your leadership role at either a children’s behavioral health care service provider or the managed care organization in the Southern Region. We appreciate the information you will share with us. Any information shared during this interview will only be included in reports such that interviewees are not personally identifiable. Any questions after the interview takes place about this study may be directed to the Principal Investigator, Melissa Johnson, at (813) 974-0397 or [email protected].

1) Please describe your organizational role and involvement in management of service provision, or contracts for services, to meet the behavioral health needs of children in licensed foster care.

2) Please share what procedures your organization has in place to assess the behavioral health needs of children in licensed foster care.

3) Are standardized assessment tools used? Which ones?

4) From your perspective, are these procedures and assessment tools adequate to identify the

behavioral health needs of children in licensed foster care?

5) Do the recommendations in the assessment drive services offered and received? Please talk a little bit about why or why not.

6) From your perspective, what are the unmet service needs of children in the region?

7) What is your opinion of current service capacity compared to the needs of the children in

care?

8) Are there commonly waiting lists for certain services? What are the services? Approximately how long are the corresponding wait lists?

9) What strategies does your organization (or your contracted providers) have in place to

ensure that children in licensed foster care have access to needed behavioral health services?

10) How does your organization interface with (other) service providers to ensure that

children in licensed foster care have access to services?

mailto:[email protected]

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11) What is your opinion of current service accessibility and how does that impact the needs of children in care?

12) What is your perspective about the current level of care coordination in the Region?

13) What recommendations do you have for improving access to and/or care coordination of

behavioral health services for children in licensed foster care?

14) Is there any other information you would like to share regarding meeting the behavioral health needs of this population in this Region?

Thank you for your time!

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Case Manager Focus Group Protocol The purpose of this focus group is to obtain information about the behavioral health services provided to children in licensed foster care in the Southern Region of Florida (Miami-Dade and Monroe Counties). We are collecting this data as part of the Southern Region Behavioral Health Services Capacity and Gap Analysis Study, which is being conducted by the University of South Florida at the request of the Department of Children and Families. You are being asked to take part in this focus group because of your role in case management in the Southern Region child welfare system. We appreciate the information you will share with us. Any information shared during this interview will only be included in reports such that participants are not personally identifiable. Any questions after the focus group takes place about this study may be directed to the Principal Investigator, Melissa Johnson, at (813) 974-0397 or [email protected].

1) Please describe your role with regard to assessing children’s behavioral health needs and coordinating behavioral health care for children in licensed foster care.

2) How do you assess the behavioral health needs of children on your caseload? Please describe the assessment process, including policies and procedures pertaining to assessment, sources of information, and any specific assessment tools that are used. How is the assessment used to inform service recommendations?

3) In your experience, how effective are these assessment processes in identifying children’s behavioral health needs? What are the challenges or limitations to assessing children’s behavioral health needs?

4) After assessment, what is the process for connecting children to appropriate services based on their identified needs? Please describe your role in this process and any specific policies or procedures.

5) What are the procedures and your role with regard to the ongoing coordination of care for children with behavioral health needs? (E.g. scheduling appointments, facilitating access to services, ensuring appointments are kept and following up when appointments are not kept, addressing barriers to care that arise.)

6) What are the procedures, and your role, in assessing changes in children’s behavioral

health needs over time? (E.g. follow up with providers, determining whether needs have been sufficiently met by services, identifying new needs that emerge over time and/or need for a change in services.)


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7) How would you describe the availability and accessibility of behavioral health services for children in licensed foster care? (E.g. Are the current array and of services and capacity of providers adequate to meet the needs of children in care? Are there services that often have long waitlists?)

8) What are the unmet behavioral health service needs of children in licensed foster care?

9) What strategies does your agency have in place to ensure that children in licensed foster care have access to needed behavioral health services?

10) What recommendations do you have for improving the availability and accessibility of behavioral health services, or coordination of care, for children in licensed foster care?

Thank you for your time!

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Provider Survey

The purpose of this survey is to obtain information about the behavioral health services provided by your agency to children in licensed foster care in the Southern Region of Florida (Miami-Dade and Monroe Counties). We are collecting this data as part of the Southern Region Behavioral Health Services Capacity and Gap Analysis Study, which is being conducted by the University of South Florida at the request of the Department of Children and Families. Please consult with the appropriate staff at your agency to complete the survey; only one survey response per agency is needed. Any questions may be directed to the Principal Investigator, Melissa Johnson, at (813) 974-0397 or [email protected].

You will be asked about a number of children’s behavioral health services. For each service, you will indicate whether your agency provides the service. For those services that your agency provides, you will be asked for additional information about service provision and capacity.

1. What is the name of your agency? _______________________

2. For which county(ies) does your agency provide behavioral health services?

Miami-Dade Monroe

3. Do staff at your agency receive training on trauma-informed care? All staff receive trauma-informed training Most staff receive trauma-informed training Some staff receive trauma-informed training No staff receive trauma-informed training

Assessment Services

4. Does your agency provide [name of assessment 1]?

Yes No – Skip to next assessment

4.a. How many staff are certified to provide [Assessment 1]? __________

4.b. How many children per week can each certified staff assess? _________


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4.c. What is the typical wait time for a child to receive an assessment after they are referred? ______________

[Repeat questions for next Assessment]

Behavioral Health Services

5. Is an individualized treatment plan developed for every child that your agency serves? Yes No

5.a. Is the treatment plan developed jointly with the child and his/her caregiver(s)?

Yes No

5.b. Please provide any additional relevant information regarding client involvement in the treatment planning process: ______________________________________

5.c. Is the child’s case manager included in developing the treatment plan?

Yes No

5.d. Is the treatment plan reviewed and updated at a minimum every six months?

Yes, always

Usually/most of the time

No, never, rarely

5.e. What role does the provider play in coordinating services with the child welfare agency? _____________________________________________________

6. Does your agency provide [Service 1]?

Yes No – Skip to next service

6.a. What are the eligibility criteria for this service? ____________________

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6.b. Which of the following behavioral health needs is this service used to address? Please mark all that apply.

Anxiety disorders

Mood disorders (depression, bipolar, etc.)

Trauma exposure/coping

Attachment disorders

Autism Spectrum disorders

Intellectual or learning disabilities

Psychosis

Attention deficit/hyperactivity/impulsivity

Self-harming behavior

Disruptive behavior/acting out

Severe conduct disorders/ anti-social behavior

Substance abuse/misuse

Victims of sexual abuse

Victims of human trafficking/ commercial sexual exploitation

Other: ______________________

6.c. How many staff at your agency are trained/certified to provide this service? ______

6.d. How many children can each trained staff carry on their caseload at a time? ______

6.e. What is the typical duration of this service? _______________

6.f. What is the treatment modality used for this service? ___________

6.g. How is this service provided?

Outpatient – In the provider’s office

Outpatient – at the client’s home/school/other community location

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Intensive outpatient – in the provider’s office

Intensive outpatient – at the client’s home/school/other location

Partial hospitalization

Inpatient

Other: ____________________

6.h. Is the service provision trauma-informed?

Yes No

6.i. How many hours per week of this service does a child typically receive?

Less than 1

1 hour

2 to 3 hours

4 to 5 hours

More than 5 hours

6.j. How many children in licensed foster care received this service from your agency during the past year? ___________

6.k. What is the typical wait time for a child to initiate this service after they are referred to your agency?

Less than 1 week

1 to 2 weeks

3 to 4 weeks

Greater than 1 month

6.l. Does your agency ever have a wait list of 6 weeks or more for this service?

Yes No

6.m. What is the funding source for this service? _______________

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[Repeat questions for next Service]

Thank you for your participation!

List of assessments and services included on survey:

Comprehensive Behavioral Health Assessment (CBHA) Psychiatric Evaluation Bio-psychosocial Evaluation Behavior Analysis Individual Therapy Family Therapy Group Therapy Behavior Management Therapeutic Support Services Medication Management Behavioral Health Day Services Targeted Case Management Crisis Stabilization Statewide Inpatient Psychiatric Program (SIPP) Specialized Therapeutic Foster Care (STFC) Specialized Therapeutic Group Home (STGH)

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Case Manager Survey

The purpose of this survey is to obtain information about the availability and accessibility of behavioral health services for children in licensed foster care in the Southern Region of Florida (Miami-Dade and Monroe Counties). We are collecting this data as part of the Southern Region Behavioral Health Services Capacity and Gap Analysis Study, which is being conducted by the University of South Florida at the request of the Department of Children and Families. Your participation in this study is voluntary; if you do not wish to participate, you do not need to complete the survey. Your responses will be kept anonymous, and we will not ask you to provide your name or any personally identifiable information. If you have questions, you may contact the Principal Investigator, Melissa Johnson, at (813) 974-0397 or [email protected].

Background Information

1. What case management agency do you work for? _________________

2. Which county do you work in?

Miami-Dade Monroe

3. What is your position?

Case Manager Supervisor Program Manager/Director Other: __________________

4. How long have you worked in your current position? ______ years _____ months

5. What is your role in the coordination of care for children in licensed foster care?


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Behavioral Health Services Capacity

Next you will be asked about a variety of behavioral health issues or needs that children in licensed foster care may have. For each identified need, you will be asked about the availability, accessibility, effectiveness, and capacity of behavioral health services to address the need. Availability refers to the extent to which services are offered and readily available (e.g. without a waitlist) in the community. Accessibility refers to the extent to which children in foster care can actually access the services, taking into account factors such as cost, insurance coverage, provider hours and location. Effectiveness refers to how well the services meet the needs of children and result in improved functioning and well-being. Capacity refers to the extent to which services are adequately available and accessible to address the level of need in the community. Please answer the questions to the best of your ability based on your knowledge and experience.

6. Answer the following questions about behavioral health services in your county to address the needs of children with anxiety issues or disorders.

a. How would you characterize the availability of behavioral health services to address the needs of children with anxiety issues or disorders?

There are no services available at all to address this need Services are somewhat available, but often have long waitlists Services are usually available, seldom have waitlists or short wait periods Services are always immediately available

b. How would you characterize the accessibility of behavioral health services to address the needs of children with anxiety issues or disorders?

Services are largely inaccessible to children in foster care Services can be difficult to access for children in foster care Services are fairly easy to access for children in foster care Services are very easy to access for children in foster care

c. How would you characterize the effectiveness of behavioral health services to address the needs of children with anxiety issues or disorders?

Services are largely ineffective and do not meet the needs of these children Services are slightly effective or somewhat meet the needs of children Services are fairly effective, able to meet the needs of many children Services are highly effective, able to meet the needs of most children

d. How would you characterize the current capacity of behavioral health services to address the needs of children with anxiety issues or disorders?

Capacity is entirely inadequate, there is a complete lack of services Capacity is largely inadequate, there are not enough services to meet the need

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Capacity is mostly adequate, there are usually enough services to meet need Capacity is completely adequate, there are plenty of services to meet the need

7. Answer the following questions about behavioral health services in your county to address the needs of children with mood disorders, such as depression or bipolar disorder.

a. How would you characterize the availability of behavioral health services to address the needs of children with mood disorders, such as depression or bipolar disorder?


b. How would you characterize the accessibility of behavioral health services to address the needs of children with mood disorders, such as depression or bipolar disorder?


c. How would you characterize the effectiveness of behavioral health services to address the needs of children with mood disorders, such as depression or bipolar disorder?


d. How would you characterize the current capacity of behavioral health services to address the needs of children with mood disorders, such as depression or bipolar disorder?

Capacity is entirely inadequate, there is a complete lack of services Capacity is largely inadequate, there are not enough services to meet the need Capacity is mostly adequate, there are usually enough services to meet need Capacity is completely adequate, there are plenty of services to meet the need

8. Answer the following questions about behavioral health services in your county to address the needs of children with attention or hyperactivity issues (e.g. ADD, ADHD).

a. How would you characterize the availability of behavioral health services to address the needs of children with attention or hyperactivity issues?

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b. How would you characterize the accessibility of behavioral health services to address the needs of children with attention or hyperactivity issues?


c. How would you characterize the effectiveness of behavioral health services to address the needs of children with attention or hyperactivity issues?


d. How would you characterize the current capacity of behavioral health services to address the needs of children with attention or hyperactivity issues?


9. Answer the following questions about behavioral health services in your county to address the needs of children with Autism Spectrum disorders.

a. How would you characterize the availability of behavioral health services to address the needs of children with Autism Spectrum disorders?


b. How would you characterize the accessibility of behavioral health services to address the needs of children with Autism Spectrum disorders?


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c. How would you characterize the effectiveness of behavioral health services to address the needs of children with Autism Spectrum disorders?


d. How would you characterize the current capacity of behavioral health services to address the needs of children with Autism Spectrum disorders?


10. Answer the following questions about behavioral health services in your county to address the needs of children with intellectual or learning disabilities.

a. How would you characterize the availability of behavioral health services to address the needs of children with intellectual or learning disabilities?


b. How would you characterize the accessibility of behavioral health services to address the needs of children with intellectual or learning disabilities?


c. How would you characterize the effectiveness of behavioral health services to address the needs of children with intellectual or learning disabilities?


d. How would you characterize the current capacity of behavioral health services to address the needs of children with intellectual or learning disabilities?

Capacity is entirely inadequate, there is a complete lack of services Capacity is largely inadequate, there are not enough services to meet the need Capacity is mostly adequate, there are usually enough services to meet need

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Capacity is completely adequate, there are plenty of services to meet the need

11. Answer the following questions about behavioral health services in your county to address the needs of children who have experienced severe and/or complex trauma.

a. How would you characterize the availability of behavioral health services to address the needs of children who have experienced severe and/or complex trauma?


b. How would you characterize the accessibility of behavioral health services to address the needs of children who have experienced severe and/or complex trauma?


c. How would you characterize the effectiveness of behavioral health services to address the needs of children who have experienced severe and/or complex trauma?


d. How would you characterize the current capacity of behavioral health services to address the needs of children who have experienced severe and/or complex trauma?


12. Answer the following questions about behavioral health services in your county to address the needs of children with psychosis.

a. How would you characterize the availability of behavioral health services to address the needs of children with psychosis?

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b. How would you characterize the accessibility of behavioral health services to address the needs of children with psychosis?


c. How would you characterize the effectiveness of behavioral health services to address the needs of children with psychosis?


d. How would you characterize the current capacity of behavioral health services to address the needs of children with psychosis?


13. Answer the following questions about behavioral health services in your county to address the needs of children with disruptive behavior issues (e.g. acting out).

a. How would you characterize the availability of behavioral health services to address the needs of children with disruptive behavior issues?


b. How would you characterize the accessibility of behavioral health services to address the needs of children with disruptive behavior issues?


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c. How would you characterize the effectiveness of behavioral health services to address the needs of children with disruptive behavior issues?


d. How would you characterize the current capacity of behavioral health services to address the needs of children with disruptive behavior issues?


14. Answer the following questions about behavioral health services in your county to address the needs of children with severe conduct problems (such as oppositional defiant disorder, anti-social behavior, delinquency problems).

a. How would you characterize the availability of behavioral health services to address the needs of children with severe conduct problems?


b. How would you characterize the accessibility of behavioral health services to address the needs of children with severe conduct problems?


c. How would you characterize the effectiveness of behavioral health services to address the needs of children with severe conduct problems?


d. How would you characterize the current capacity of behavioral health services to address the needs of children with severe conduct problems?

Capacity is entirely inadequate, there is a complete lack of services Capacity is largely inadequate, there are not enough services to meet the need

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Capacity is mostly adequate, there are usually enough services to meet need Capacity is completely adequate, there are plenty of services to meet the need

15. Answer the following questions about behavioral health services in your county to address the needs of children with attachment issues or disorders.

a. How would you characterize the availability of behavioral health services to address the needs of children with attachment issues or disorders?


b. How would you characterize the accessibility of behavioral health services to address the needs of children with attachment issues or disorders?


c. How would you characterize the effectiveness of behavioral health services to address the needs of children with attachment issues or disorders?


d. How would you characterize the current capacity of behavioral health services to address the needs of children with attachment issues or disorders?


16. Answer the following questions about behavioral health services in your county to address the needs of children who have experienced sexual abuse.

a. How would you characterize the availability of behavioral health services to address the needs of children who have experienced sexual abuse?

There are no services available at all to address this need Services are somewhat available, but often have long waitlists Services are usually available, seldom have waitlists or short wait periods

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Services are always immediately available

b. How would you characterize the accessibility of behavioral health services to address the needs of children who have experienced sexual abuse?


c. How would you characterize the effectiveness of behavioral health services to address the needs of children who have experienced sexual abuse?


d. How would you characterize the current capacity of behavioral health services to address the needs of children who have experienced sexual abuse?


17. Answer the following questions about behavioral health services in your county to address the needs of children with substance abuse issues.

a. How would you characterize the availability of behavioral health services to address the needs of children with substance abuse issues?


b. How would you characterize the accessibility of behavioral health services to address the needs of children with substance abuse issues


c. How would you characterize the effectiveness of behavioral health services to address the needs of children with substance abuse issues?

Services are largely ineffective and do not meet the needs of these children

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Services are slightly effective or somewhat meet the needs of children Services are fairly effective, able to meet the needs of many children Services are highly effective, able to meet the needs of most children

d. How would you characterize the current capacity of behavioral health services to address the needs of children with substance abuse issues?


18. Answer the following questions about behavioral health services in your county to address the needs of children who exhibit suicidal or self-harming behavior.

a. How would you characterize the availability of behavioral health services to address the needs of children who exhibit suicidal or self-harming behavior?


b. How would you characterize the accessibility of behavioral health services to address the needs of children who exhibit suicidal or self-harming behavior?


c. How would you characterize the effectiveness of behavioral health services to address the needs of children who exhibit suicidal or self-harming behavior?


d. How would you characterize the current capacity of behavioral health services to address the needs of children who exhibit suicidal or self-harming behavior?


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19. Answer the following questions about behavioral health services in your county to address the needs of children who have experienced human trafficking (including commercial sexual exploitation, labor trafficking, or domestic servitude).

a. How would you characterize the availability of behavioral health services to address the needs of children who have experienced human trafficking?


b. How would you characterize the accessibility of behavioral health services to address the needs of children who have experienced human trafficking?


c. How would you characterize the effectiveness of behavioral health services to address the needs of children who have experienced human trafficking?


d. How would you characterize the current capacity of behavioral health services to address the needs of children who have experienced human trafficking?


20. Answer the following questions about therapeutic placement options (e.g. therapeutic foster care, specialized therapeutic foster care, therapeutic group care) in your county.

a. How would you characterize the availability of therapeutic placement options for children in need of this level of care?


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b. How would you characterize the accessibility of therapeutic placement options for children in need of this level of care?


c. How would you characterize the effectiveness of therapeutic placement options for children in need of this level of care?


d. How would you characterize the current capacity of therapeutic placement options for children in need of this level of care?


21. Answer the following questions about residential care (e.g. SIPP, inpatient substance abuse, etc.) in your county.

a. How would you characterize the availability of residential care for children in need of this level of care?


b. How would you characterize the accessibility of residential care for children in need of this level of care?


c. How would you characterize the effectiveness of residential care for children in need of this level of care?

Services are largely ineffective and do not meet the needs of these children Services are slightly effective or somewhat meet the needs of children Services are fairly effective, able to meet the needs of many children

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Services are highly effective, able to meet the needs of most children

d. How would you characterize the current capacity of residential care for children in need of this level of care?


22. Based on your experience, what are the most significant gaps in behavioral health services for foster care children in your community?

Thank you for your participation!

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Appendix B

Mental Health Assessments used by Behavioral Health Providers

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Children’s Mental Health Assessments and Screening Instruments

Screening Instrument Brief Description

GAIN-Q The GAIN-Q3 is a brief screener used to identify and address a wide range of problems. It is designed to be used in diverse settings (i.e. child welfare, health clinics, juvenile justice). Domains include: problems and service utilization, substance use, mental health (internalizing and externalizing problems), crime and violence, stress, physical health, school and work, and quality of life. http://gaincc.org/instruments/

GAIN-I

The GAIN-I is a comprehensive bio-psychosocial assessment intended to support clinical diagnosis, placement, treatment planning, performance monitoring, and program planning. It is designed to be used primarily in clinical settings. Domains include: background, substance use, physical health, risk behaviors and disease prevention, mental and emotional health, environment and living situation, legal, and vocational. http://gaincc.org/instruments/

Youth Level of Service/Case Management Inventory (YLS/CMI)

The Youth Level of Service/Case Management Inventory is intended to assess rehabilitation needs. It is used with 12-18-year-old youth who have a juvenile offense. It examines likelihood of re-offending as well as providing an opportunity for users to evaluate positive client attributes so that client strengths may be highlighted and built upon in service delivery. The YLS/CMI provides an estimate of risk of reconviction for individual offenders over twelve months. https://www.cognitivecentre.com/assessment/youth-level-servicecase-management-inventory-ylscmi-2-0-new/

Adverse Childhood Experiences (ACES) Tool

The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study is one of the largest investigations of childhood abuse and neglect and household challenges and later-life health and well-being. The Family Health History and Health Appraisal questionnaires were used to collect information on child abuse and neglect, household challenges, and other socio-behavioral factors in the original CDC-Kaiser ACE Study. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Clinical-Assessment-Tools.aspx

SBIRT

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice used to identify, reduce, and prevent substance abuse. The SBIRT consists of three major components: Screening — assessment of any risky substance use behaviors using standardized screening tools. Brief Intervention — child-serving professional engages client showing risky substance use behaviors in a short conversation, providing feedback and advice Referral to Treatment — child-serving professional provides a referral to brief therapy or additional treatment to clients who screen in need of additional services

http://gaincc.org/instruments/

http://gaincc.org/instruments/

https://www.cognitivecentre.com/assessment/youth-level-servicecase-management-inventory-ylscmi-2-0-new/

https://www.cognitivecentre.com/assessment/youth-level-servicecase-management-inventory-ylscmi-2-0-new/

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Clinical-Assessment-Tools.aspx

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Clinical-Assessment-Tools.aspx

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https://www.integration.samhsa.gov/clinical-practice/sbirt#why? Youth Outcome Questionnaire (completed by parents) Youth Outcomes Self Repot (completed by youth)

The Youth Outcome Questionnaire is a collection of questions aimed at collecting data regarding the effectiveness of youth therapies. The Y-OQ is a parent report measure of treatment progress for children and adolescents (ages 4 – 17) receiving mental health interventions. The Y-OQ–SR is an adolescent self-report measure appropriate for ages 12 – 18. The Y-OQ measures six subscales: Intrapersonal Distress (ID), Somatic (S), Interpersonal Relationships (IR), Critical Items (CI), Social Problems (SP), and Behavioral Dysfunction (BD). The subscale scores can be used to identify and target particularly problematic areas as a focus of treatment and help with treatment planning. The YOQ was developed by Dr. Michael Lambert and Dr. Gary Burlingame with more information: https://www.oqmeasures.com/

Therapist Outcome Measure (TOM; completed by therapist pre and post) Client Outcome Measure (COM; completed by youth pre and post)

The Therapy Outcome Measure (TOM) is a brief outcome measure that allows professionals to describe the relative abilities and difficulties of a client in the four domains of ‘impairment’, ‘activity’, ‘participation’ and ‘wellbeing’ in order to monitor changes over time. It is used for treatment planning, clinical management, audit and research. It allows for the aggregation of data so that comparisons can be made that may be suitable for internal and external benchmarking. http://www.communitytherapy.org.uk/TOM.html

ADAD ADAD is a 150-item instrument conducted as a structured interview that yields a comprehensive evaluation of clients and provides a 10-point severity rating for each of 9 life problem areas. Composite scores to measure client behavioral change in each life problem area, during and after treatment, can be calculated. The ADAD’s primary purpose is to assess substance abuse and other life problems (e.g., medical, school, employment, social relations, family, psychological, legal, alcohol and drug use), to assist with treatment planning, and to assess changes in life problem areas and severity over time. http://www.emcdda.europa.eu/html.cfm/index3530EN.html

PHQ2 and PHQ9 depression screenings

The Patient Health Questionnaire-2 (PHQ-2) asks about the frequency of depressed mood over the past two weeks. The purpose of the PHQ-2 is to screen for depression in a “first-step” approach. Patients who screen positive should be further evaluated with the PHQ-9 to determine whether they meet criteria for a depressive disorder. https://www.hiv.uw.edu/page/mental-health-screening/phq-2 Patient Health Questionnaire-9 (PHQ-9) The PHQ-9 is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression. https://www.hiv.uw.edu/page/mental-health-screening/phq-9

Columbia Suicide Rating Scale

The Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS), supports suicide risk assessment

https://www.integration.samhsa.gov/clinical-practice/sbirt#why?

https://www.oqmeasures.com/

http://www.communitytherapy.org.uk/TOM.html

http://www.emcdda.europa.eu/html.cfm/index3530EN.html

https://www.hiv.uw.edu/page/mental-health-screening/phq-2

https://www.hiv.uw.edu/page/mental-health-screening/phq-9

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through a series of simple, plain-language questions. The answers help users identify whether someone is at risk for suicide, assess the severity and immediacy of that risk, and assess the level of support that the client may need. Question items include whether and when clients have thought about suicide (ideation), what actions they have taken to prepare for suicide, and whether and when they attempted suicide or began a suicide attempt that was interrupted or stopped of their own accord. http://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/

http://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/

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Appendix C

Evidence-Based Practices and Treatment Modalities

147


List of Evidence-based Treatments reported by providers

Treatment Model # of providers Cognitive Behavior Therapy (CBT) 17 Trauma-Focused Cognitive Behavior Therapy (TF-CBT) 9 Dialectical Behavior Therapy (DBT) 5 Motivational Interviewing 8 Solution Focused Behavior Therapy (SFBT) 5 Play Therapy 5 Child-Parent Psychotherapy (CPP) 4 Emotionally Focused Family Therapy 3 Mindfulness Based Cognitive Therapy (MBCT) 3 Person Centered Therapy 2 Motivational Enhancement Therapy 1 Acceptance and Commitment Therapy (ACT) 1 Internal Family Systems 1 Parent-Child Interaction Therapy (PCIT) 1 Family Functional Therapy 1 Attachment-based Therapy 1 Rational Emotive Behavior Therapy (REBT) 1

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Appendix D

Behavioral Health Provider Survey Results

149


Children’s Behavioral Health Assessment Capacity Assessment County # of agencies # of staff children/week avg. wait time Comprehensive Behavioral Health Assessment

Miami-Dade Monroe

6 1

4* Unknown*

Unknown* Unknown*

1 – 21 days Unknown*

Psychiatric Evaluation Miami-Dade Monroe

10 3

18 8

154* 27

2 – 30 days 7 – 10 days

Bio-psychosocial Evaluation

Miami-Dade Monroe

12 3

126 13

1001* 65

2 – 15 days 1 – 7 days

*Multiple agencies did not know or did not respond to this question; reported numbers are presumed to be an underestimate due to these missing data

Children’s Behavioral Health Treatment Services Capacity

Service Count

y

# of agenci

es # staff

Avg. caseloa

d Avg.

Duration

Avg. hours/we

ek

# served in past year

Avg. wait time

Funding

source(s)

Behavioral Analysis

Miami-Dade

Monroe

2 0

2* -

20 -

6 mo. -

2 – 3 -

71 -

< 1 week -

Medicaid

Individual Therapy

Miami-Dade

Monroe

12 4

116 38

12 – 35 5 – 25

3 – 12 mo.

3 – 12 mo.

1 – 3 1

2081* 40*

< 1 week < 1 week

Medicaid, DCF,

ME, CBC

Family Therapy

Miami-Dade

Monroe

11 3

101 17

5 – 30 5 – 20

6 – 12 mo.

6 – 12 mo.

1 1

1405* 30*

1 – 2 weeks 1 – 2 weeks

Medicaid, ME, DCF

Group Therapy

Miami-Dade

Monroe

6 -

41 -

20* -

4 – 6 mo. -

1 – 2 -

71* -

1 – 4 weeks

-

Medicaid, DCF

Behavior Management

Miami-Dade

Monroe

2 -

Unknown -

Unknown -

Unknown -

Unknown -

Unknown -

Unknown -

Unknown -

Therapeutic Support Services

Miami-Dade

Monroe

5 1

26* Unkno

wn

1 – 30 Unkno

wn

1 wk. – 9 mo.

Unknown

1 – 5 Unknown

70* Unkno

wn

1 – 2 weeks

Unknown

Medicaid, ME, DCF

Medication Management

Miami-Dade

Monroe

10 3

42* 8

25 – 60*

15+*

Unspecified “

< 1 < 1

1285* 100*

1 – 4 weeks <1 – 4 weeks

Medicaid, ME, DCF,

insurance

Targeted Case Management

Miami-Dade

Monroe

4 1

24 4

15 – 30 20

6 – 12 mo.

6 – 12 mo.

2 – 3 1

1080* 100

1 – 4 weeks

< 1 week

Medicaid, ME, DCF

Crisis Stabilization

Miami-Dade

Monroe

1 1

Unknown 30

16 beds Unkno

wn

72 hours 24 hours

5+ < 1

Unknown

Unknown

Immediate

Immediate

Medicaid, DCF

150


Mobile Response

Miami-Dade

Monroe

1 1

4 15

N/A N/A

1 – 2 hours 1 – 2 hours

- -

Unknown

Unknown

Immediate

Immediate

ME, DCF

SIPP Miami-Dade

Monroe

1 -

Unknown -

44 beds -

Unknown -

Unknown -

Unknown -

Unknown -

Medicaid, DCF

STFC Miami-Dade

Monroe

3 -

20* -

1 – 2 -

9 – 12 mo.

-

24/7 -

30* 1 – 2 weeks

-

Medicaid

*One or more agencies did not know or did not respond to this question; reported numbers are presumed to be an underestimate due to these missing data.

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Appendix E

Case Management Survey Results

152


Case Management Perceptions of Children’s Behavioral Health Services

Behavioral Health Need Availability1 Accessibility2 Effectiveness3 Capacity4

Anxiety Not available 0% Largely inaccessible 0% Largely ineffective 10.5% Entirely inadequate 2.6% Somewhat available 51.4% Difficult to access 44.7% Slightly effective 34.2% Largely inadequate 39.5% Usually available 37.8% Fairly easy to access 42.1% Fairly effective 47.4% Mostly adequate 52.6% Always available 10.8% Very easy to access 13.2% Highly effective 7.9% Completely adequate 5.3%

Mood disorders

Not available 0% Largely inaccessible 0% Largely ineffective 9.1% Entirely inadequate 6.1% Somewhat available 46.9% Difficult to access 45.5% Slightly effective 30.3% Largely inadequate 36.4% Usually available 50.0% Fairly easy to access 45.5% Fairly effective 51.5% Mostly adequate 57.6% Always available 3.1% Very easy to access 9.1% Highly effective 9.1% Completely adequate 6.1%

Attention/ hyperactivity

Not available 4.2% Largely inaccessible 3.6% Largely ineffective 7.1% Entirely inadequate 3.6% Somewhat available 50.0% Difficult to access 46.4% Slightly effective 35.7% Largely inadequate 39.3% Usually available 37.5% Fairly easy to access 42.9% Fairly effective 50.0% Mostly adequate 46.4% Always available 8.3% Very easy to access 7.1% Highly effective 7.1% Completely adequate 10.7%

Autism spectrum

Not available 0% Largely inaccessible 4.2% Largely ineffective 0% Entirely inadequate 8.0% Somewhat available 70.8% Difficult to access 58.3% Slightly effective 52.0% Largely inadequate 44.0% Usually available 29.2% Fairly easy to access 37.5% Fairly effective 44.0% Mostly adequate 48.0% Always available 0% Very easy to access 0% Highly effective 4.0% Completely adequate 0%

Intellectual/ learning disabilities

Not available 8.0% Largely inaccessible 8.0% Largely ineffective 8.0% Entirely inadequate 8.0% Somewhat available 56.0% Difficult to access 48.0% Slightly effective 44.0% Largely inadequate 44.0% Usually available 32.0% Fairly easy to access 40.0% Fairly effective 44.0% Mostly adequate 48.0% Always available 4.0% Very easy to access 4.0% Highly effective 4% Completely adequate 0%

Severe/ complex trauma

Not available 13.6% Largely inaccessible 13.0% Largely ineffective 18.2% Entirely inadequate 13.0% Somewhat available 54.5% Difficult to access 60.9% Slightly effective 50.0% Largely inadequate 47.8% Usually available 31.8% Fairly easy to access 26.1% Fairly effective 31.8% Mostly adequate 39.1% Always available 0% Very easy to access 0% Highly effective 0% Completely adequate 0%

Psychosis Not available 28.6% Largely inaccessible 25.0% Largely ineffective 20.8% Entirely inadequate 20.8% Somewhat available 42.9% Difficult to access 41.7% Slightly effective 45.8% Largely inadequate 37.5% Usually available 28.6% Fairly easy to access 33.3% Fairly effective 33.3% Mostly adequate 41.7% Always available 0% Very easy to access 0% Highly effective 0% Completely adequate 0%

Disruptive behavior

Not available 22.7% Largely inaccessible 13.0% Largely ineffective 17.4% Entirely inadequate 13.0% Somewhat available 50.0% Difficult to access 56.5% Slightly effective 56.5% Largely inadequate 56.5% Usually available 27.3% Fairly easy to access 30.4% Fairly effective 26.1% Mostly adequate 26.1% Always available 0% Very easy to access 0% Highly effective 0% Completely adequate 4.3%

Conduct problems

Not available 21.7% Largely inaccessible 13.0% Largely ineffective 21.7% Entirely inadequate 13.0% Somewhat available 60.9% Difficult to access 69.6% Slightly effective 56.5% Largely inadequate 69.6% Usually available 17.4% Fairly easy to access 17.4% Fairly effective 21.7% Mostly adequate 17.4%

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Always available 0% Very easy to access 0% Highly effective 0% Completely adequate 0% Attachment issues

Not available 8.0% Largely inaccessible 8.0% Largely ineffective 12.5% Entirely inadequate 8.0% Somewhat available 36.0% Difficult to access 32.0% Slightly effective 33.3% Largely inadequate 28.0% Usually available 52.0% Fairly easy to access 56.0% Fairly effective 54.2% Mostly adequate 60.0% Always available 4.0% Very easy to access 4.0% Highly effective 0% Completely adequate 4.0%

Sexual abuse Not available 4.3% Largely inaccessible 4.3% Largely ineffective 17.4% Entirely inadequate 4.3% Somewhat available 43.5% Difficult to access 34.8% Slightly effective 43.5% Largely inadequate 47.8% Usually available 47.8% Fairly easy to access 56.5% Fairly effective 34.8% Mostly adequate 43.5% Always available 4.3% Very easy to access 4.3% Highly effective 4.3% Completely adequate 4.3%

Substance abuse


Self-harming behavior


Human trafficking


Therapeutic placements

Not available 17.4% Largely inaccessible 21.7% Largely ineffective 26.1% Entirely inadequate 30.4% Somewhat available 65.2% Difficult to access 60.9% Slightly effective 43.5% Largely inadequate 43.5% Usually available 17.4% Fairly easy to access 17.4% Fairly effective 30.4% Mostly adequate 26.1% Always available 0% Very easy to access 0% Highly effective 0% Completely adequate 0%

Residential care


1Availability refers to the extent to which services are offered and readily available (e.g. without a waitlist) in the community. 2Accessibility refers to the extent to which children in foster care can actually access the services, taking into account factors such as cost, insurance coverage, provider hours and location. 3Effectiveness refers to how well the services meet the needs of children and result in improved functioning and well-being. 4Capacity refers to the extent to which services are adequately available and accessible to address the level of need in the community.

154

Appendix F

Definitions for Administrative Data Analysis

155

Cost Center Definitions:

1. Assessment. Assessment services assess, evaluate, and provide assistance to individuals

and families to determine level of care, motivation, and the need for services and supports

to assist individuals and families identify their strengths.

2. Case Management. Case management services consist of activities aimed at identifying

the recipient’s needs, planning services, linking the service system with the person,

coordinating the various system components, monitoring service delivery and evaluating

the effect of the services received.

3. Crisis Stabilization. These acute care services provide, on a twenty-four (24) hours per

day, seven (7) days per week basis, brief, intensive mental health residential treatment

services to meet the needs of individuals who are experiencing an acute crisis and who, in

the absence of a suitable alternative, would require hospitalization.

4. Crisis Support / Emergency. These non-residential care services are generally available

twenty-four (24) hours per day, seven (7) days per week, or some other specific time

period, to intervene in a crisis or provide emergency care. Examples include: mobile

crisis, crisis support, crisis/emergency screening, crisis telephone, and emergency walk-

in.

5. Day Care Services. Day care services provide a structured schedule of activities for four

(4) or more consecutive hours per day for children of persons who are participating in a

mental health or substance abuse day – night service or residential services.

6. Day / Night. Day-night services provide a structured schedule of non-residential services

for four (4) or more consecutive hours per day. Activities for children and adult mental

health programs are designed to assist individuals attain skills and behaviors needed to

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function successfully in living, learning, work, and social environments. Generally, a

person receives three (3) or more services a week. Activities for substance abuse

programs emphasize rehabilitation, treatment, and education services, using

multidisciplinary teams to provide integrated programs of academic, therapeutic, and

family services.

7. Drop In / Self Help Centers. These centers are intended to provide a range of

opportunities for persons with severe and persistent mental illness to independently

develop, operate and participate in social, recreational, and networking activities.

8. In-Home And On – Site Services Overlay. Therapeutic services and supports are

rendered in non-provider settings such as nursing homes, alternative living facilities

(ALFs), residences, schools, detention centers, commitment settings, foster homes, and

other community settings.

9. Inpatient. Inpatient services are provided in hospitals, licensed under Chapter 395,

Florida Statutes, as general hospitals and psychiatric specialty hospitals. They are

designed to provide intensive treatment to persons exhibiting violent behaviors, suicidal

behaviors and other severe disturbances due to substance abuse or mental illness.

10. Intensive Case Management. Case management services consist of activities aimed at

assessing recipient needs, planning services, linking the service system to a recipient,

coordinating the various system components, monitoring service delivery and evaluating

the effect of services received. These services are typically offered to persons who are

being discharged from a hospital or crisis stabilization unit, who are in need of more

professional care, and who will have contingency needs to remain in a less restrictive

setting.

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11. Intervention. Intervention services focus on reducing risk factors generally associated

with the progression of substance abuse and mental health problems. Intervention is

accomplished through early identification of persons at risk, performing basic individual

assessments, and providing supportive services, which emphasize short-term counseling

and referral. These services are targeted toward individuals and families.

12. Medical Services. Medical services provide primary medical care, therapy and

medication administration to improve the functioning or prevent further deterioration of

persons with mental health or substance abuse problems. Included is psychiatric mental

status assessment.

a. For adults with mental illness, medical services are usually provided on a regular

schedule, with arrangements for non-scheduled visits during times of increased

stress or crisis. This service includes medication administration of psychotropic

drugs including Clozaril and other new medications, and psychiatric services.

13. Methadone Maintenance. Methadone medication maintenance consists of a group of

outpatient services, which utilize methadone and other opioid replacement therapies,

where permitted, in conjunction with assessment, rehabilitation and treatment services.

14. Outpatient-Individual. Outpatient services provide a therapeutic environment that is

designed to improve the functioning or prevent further deterioration of persons with

mental health and/or substance abuse problems. These services are usually provided on a

regularly scheduled basis by appointment, with arrangements made for non-scheduled

visits during times of increased stress or crisis.

15. Outreach. Outreach services are provided through a formal program to both the

community at large and to individuals. Community services include education,

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identification and linkage with high risk groups. Outreach services for individuals are

designed to: encourage, educate, and engage prospective clients who show an indication

of substance abuse and mental health problems or needs. Client enrollment is not

included in outreach services.

16. Prevention. Prevention services are those involving strategies that preclude, forestall, or

impede the development of substance abuse and mental health problems, and include

increasing public awareness through information dissemination, education, and

alternative-focused activities. These services may be directed either toward a Level II

prevention target where the client has been identified, or at a Level I prevention target

where the client is not identifiable.

17. Prevention / Intervention Day. This cost center includes school-based day services for

children and adolescents for four (4) or more consecutive hours per day. These services

include school-based mental health services for children who have been identified by the

school as being at risk of developing, mental health problems. Services are

individualized and may be provided in a self-contained classroom, a regular classroom, or

as a component of a full service school.

18. Residential Level I. These licensed facilities provide structured, live-in, non-hospital

setting, services with supervision on a twenty-four (24) hours per day, seven (7) days per

week basis. There is a nurse on duty in these facilities at all times. For adult mental

health, these services include group homes, which are for longer-term residents. These

facilities offer nursing supervision provided by, at a minimum, licensed practical nurses

on a twenty-four (24) hours per day, seven (7) days per week basis. For children with

serious emotional disturbances, Level I services are the most intensive and restrictive

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level of residential therapeutic intervention provided in a non-hospital or non-crisis

support setting, including residential treatment centers. Medicaid Residential Treatment

Centers (MRTC) and Residential Treatment Centers (RTC) are reported under this cost

center. On-call medical care must be available for substance abuse programs. For

substance abuse, Level I services provide a range of assessment, treatment, rehabilitation,

and ancillary services in an intensive therapeutic environment, with an emphasis on

treatment, and may include formal school and adult education programs.

19. Residential Level II. These are licensed, structured rehabilitation-oriented group

facilities that have twenty-four (24) hours per day, seven (7) days per week, supervision.

Level II facilities are for persons who have significant deficits in independent living skills

and need extensive support and supervision. For children with serious emotional

disturbances, Level II services are programs specifically designed for the purpose of

providing intensive therapeutic behavioral and treatment interventions. This cost center

includes services provided in Therapeutic Group Homes (TGH), Specialized Therapeutic

Foster Homes (STFH) – Level I, and Therapeutic Foster Homes (TFH) – Level I. For

substance abuse, Level II services provide a range of assessment, treatment,

rehabilitation, and ancillary services in a less intensive therapeutic environment with an

emphasis on rehabilitation, and may include formal school and adult educational

programs.

20. Residential Level III. These are licensed facilities which provide twenty-four (24) hours

per day, seven (7) days per week supervised residential alternatives to persons who have

developed a moderate functional capacity for independent living. For adults with serious

mental illness, this cost center consists of supervised apartments. For children with

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serious emotional disturbances, Level III services are services specifically designed to

provide sparse therapeutic behavioral and treatment interventions. This cost center

provides services in Therapeutic Group Homes (TGH), Specialized Therapeutic Foster

Homes (STFH)-Level I, and Therapeutic Foster Homes (TFH) – Level I. For substance

abuse, Level III provides a range of assessment, rehabilitation, treatment and ancillary

services on a long-term, continuing care basis where, depending upon the characteristics

of the clients served, the emphasis is on rehabilitation or treatment.

21. Residential Level IV. This type of facility may have less than twenty-four (24) hours

per day, seven (7) days per week on-premise supervision. This is the least intensive level

of residential care. It is primarily a support service and, as such, treatment services are

not included in this cost center. For adult mental health, Level IV includes satellite

apartments, satellite group homes and therapeutic foster homes. For children with

serious emotional disturbances, Level IV services are the least intensive and restrictive

levels of residential care provided in group or foster homes settings, therapeutic foster

homes, and group care. Note: Regular therapeutic foster care can be provided either

through Residential Level IV “Day of Care: TFH” or by billing in-home/non-provider

setting for a child in a foster home.

22. Respite Services. Respite care services are designed to sustain the family or other

primary caregiver by providing time-limited, temporary relief from the ongoing

responsibility of care giving. Although the respite is for the caregiver, use the SSN of the

client in question.

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23. Sheltered Employment. Sheltered employment services are non-competitive

employment services within a work-based facility; it requires federal exemption from the

Minimum Wage Act.

24. Substance Abuse Detoxification. Detoxification programs use medical and clinical

procedures in a residential setting to assist adults, children and adolescents with

substance abuse problems in their efforts to withdraw from the physiological and

psychological effects of substance abuse. Residential detoxification and Addiction

Receiving Facilities (ARFs) provide emergency screening, evaluation, short-term

stabilization, and treatment in a secure environment. The maximum unit cost rate for a

Juvenile Addiction Receiving Facility that is integrated with a Children’s Crisis

Stabilization Unit shall be the maximum unit cost rate for the Crisis Stabilization cost

center rather than for the Substance Abuse Detoxification cost center.

25. Supported Employment. Supported employment services are community-based

employment services in an integrated work setting, which provides regular contact with

non-disabled co-workers or the public. A job coach provides long-term, ongoing support

for as long as it is needed to enable the person served to maintain employment.

26. Supported Housing/Living. Supported housing/living services assist persons with

substance abuse or psychiatric disabilities in the selection of housing of their choice.

These services also provide the necessary services and supports to assure their continued

successful living in the community and transitioning into the community. For children

with mental health problems, supported living is the process of assisting adolescents in

arranging for housing and providing services to assure successful transition to living

independently on their own or with roommates in the community. Services include

162


training in independent living skills. For substance abuse, services provide for the

placement and monitoring of recipients who: (a) are participating in non-residential

services, (b) have completed or are completing substance abuse treatment, and (c) need

assistance and support in independent or supervised living within a live-in environment.

27. TASC. Treatment Accountability for Safer Communities (TASC) provides for

identification, screening, court liaison, referral and tracking of persons in the criminal

justice system with a history of drug abuse or addiction.

28. Incidental Expenses. This cost center provides for incidental expenses for items, such

as clothing, medical care, educational needs, developmental services, FACT Team

housing subsidies and pharmaceuticals, (if not required by the Request for Proposal –

RFP to be reimbursed through a separate cost reimbursement contract) and other

approved costs. All incidental expenses must be included in the contract or must have

prior written authorization from authorized department staff member.

29. Aftercare/Follow-up. Aftercare services, including but not limited to relapse

prevention, are a vital part of recovery in every treatment level. Aftercare activities

include client participation in daily activity functions, which were adversely affected by

mental illness and/or substance abuse impairments. New directional goals such as

vocational education or re-building relationships are often priorities. Relapse prevention

issues are key in assisting the client’s recognition of triggers and warning signs of

regression. Aftercare services help families and pro-social support systems reinforce a

healthy living environment.

30. Information and Referral. These services maintain information about resources in the

community, link people who need assistance with appropriate service providers, and

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provide information about agencies and organizations that offer services. The

information and referral process involves being readily available for contact by the

individual; assisting the individual with determining which resources are needed;

providing referral to appropriate resources; and following up to ensure the individual’s

needs have been met, if the individual agrees to such follow-up activities.

31. Behavioral Health Overlay Services (BHOS). Medicaid funded behavioral health

services provided as an overlay to residential group care.

32. Outpatient Detoxification. Outpatient detoxification services utilize medication and/or

psychosocial counseling regimen to assist recipients in their efforts to withdraw from the

physiological and psychological effects of the abuse of addictive substances.

33. FACT Team. These non-residential care services are available twenty-four (24) hours

per day, seven (7) days per week, and include community-based treatment, rehabilitation

and support services provided by a multidisciplinary team to persons with severe and

persistent mental illness (SPMI) or to SPMI with co-occurring disorders.

34. Outpatient-Group. This cost center provides a therapeutic environment that is designed

to improve the functioning or prevent further deterioration of persons with mental health

and/or substance abuse problems. Outpatient-group services are usually provided on a

regularly scheduled basis by appointment, with arrangements made for non-scheduled

visits during times of increased stress or crisis. The group size limitations applicable to

the Medicaid program shall apply to all outpatient services funded through a state

substance abuse and mental health program contract.

35. Room & Board w/Supervision, Level I. This cost center solely provides for room and

board with supervision on a twenty-four (24) hours per day, seven (7) days per week

164


basis. It corresponds to Residential Level I. This cost center is not applicable for

provider facilities which meet the definition of an Institute for Mental Disease (IMD) as

defined in the Center for Medicaid Service’s State Medicaid Manual, Section 4, March

1994.

36. Room & Board w/Supervision, Level II. This cost center corresponds to cc [19] above

for Residential Level II; same programs, units and data elements as cc [36] above for

Room and Board with Supervision Level I

37. Room & Board w/Supervision, Level III. This cost center corresponds to cc [20] above

for Residential Level III; same programs, units and data elements as cc [36] above for

Room and Board with Supervision Level I.

38. Short-term Residential Treatment. These individualized, stabilizing acute and

immediately sub acute care services provide short and intermediate duration intensive

mental health residential and habilitative services on a twenty-four (24) hour per day,

seven (7) days per week basis. These services must meet the needs of individuals who

are experiencing an acute or immediately sub acute crisis and who, in the absence of a

suitable alternative, would require hospitalization.

39. Mental Health Clubhouse Services. This cost center provides structured, community-

based services designed to strengthen and/or regain the client’s interpersonal skills,

provide psycho-social therapy toward rehabilitation, develop the environmental supports

necessary to help the client thrive in the community and meet employment and other life

goals and promote recovery from mental illness. Services are typically provided in a

community-based program with trained staff and members working as teams to address

the client’s life goals and to perform the tasks necessary for the operations of the

165


program. The emphasis is on a holistic approach focusing on the client’s strengths and

abilities while challenging the client to pursue those life goals. This service would

include, but not limited to, clubhouses certified under the International Center for

Clubhouse Development.

40. Project Recovery. Project Recovery is designed to enhance and extend the state’s

capacity to serve individuals with severe emotional issues beyond the scope of crisis

counseling. The project uses multidisciplinary teams located in selected counties to

provide assessments, referrals, service planning, direct services and the purchase of

therapeutic service from other providers to reduce the effects of trauma or other

emotional effects resulting from the storms.

41. Intervention – Group. Intervention services focus on reducing risk factors generally

associated with the progression of substance abuse and mental health problems.

Intervention is accomplished through early identification of persons at risk, performing

basic individual assessments, and providing supportive services that emphasize short-

term counseling and referral. These services are targeted toward individuals and families.

This cost center is used when reporting an individual’s services which are provided in a

group environment. Each individual within the group would have separate service event

record to record group participation.

42. Aftercare – Group. This cost center includes services provided to individuals who have

completed treatment in a licensable service component. Aftercare activities include client

participation in daily activity functions which were adversely affected by mental illness

or substance abuse impairments. New directional goals such as vocational education or

re-building relationships are often priorities. Relapse prevention issues are key in

166


assisting the client’s recognition of triggers and warning signs of regression. Aftercare

services help families and pro-social support systems reinforce a healthy living

environment. This cost center is used when reporting an individual’s services which are

provided in a group environment. Each individual within the group would have a

separate service event record to record group participation.

43. Comprehensive Community Service Team – Individual. Comprehensive Community

Service Team (CCST) services render assistance in identifying goals and making choices

to promote resiliency and facilitate recovery to adults and children with mental illness.

The services take place in either an outpatient or community based setting. For

individuals with mental health problems, recovery is the personal process of overcoming

the negative impact of psychiatric illness despite its continued presence. CCST services

are intended to restore the individual’s function and participation in the community. The

services are designed to assist and guide individuals in reconnecting with society and

rebuilding skills in identified roles in their environment. The focus is on the individual

strengths and resources as well as their readiness and phase of recovery. A team

approach to services will be used to guide and support the adults and children served with

development of a recovery plan focusing on the areas of individual and family living,

learning, working and socialization activities. Any therapy is brief and oriented toward

skill building.

44. Comprehensive Community Service Team – Group. Comprehensive Community

Service Team (CCST) services render assistance in identifying goals and making choices

to promote resiliency and facilitate recovery to adults and children with mental illness,

the services take place in either an outpatient or community based setting. For

167


individuals with mental health problems, recovery is the personal process of overcoming

the negative impact of psychiatric illness despite its continued presence. CCST services

are intended to restore the individual’s function and participation in the community. The

services are designed to assist and guide individuals in reconnecting with society and

rebuilding skills in identified roles in their environment. The focus is on the individual

strengths and resources as well as their readiness and phase of recovery. A team

approach of services will be used to guide and support the adults and children served with

development of a recovery plan focusing on the areas of individual and family living,

learning, working and socialization activities. Any therapy is brief and oriented toward

skill building.

45. Substance Abuse Recovery Support Services – Individual. These services are

designed to strengthen and/or regain the person’s skills, and to assist the person in

developing the environmental support necessary to help him or her thrive in the

community and meet life goals which promote recovery and resiliency. The focus is on

person strengths and abilities while providing support for progress toward the person

achieving recovery goals reflected in the person’s screening, assessment, treatment plan,

or discharge summary.

46. Substance Abuse Recovery Support Services – Group. These services are designed to

strengthen and/or regain the person’s skills, and to assist the person in developing the

environmental support necessary to help him or her thrive in the community and meet life

goals which promote recovery and resiliency. The focus is on person strengths and

abilities while providing support for progress toward the person achieving recovery goals

reflected in the person’s screening, assessment, treatment plan, or discharge summary.

Documents

Final evaluation report - Florida Department of Children ... Region Gap … · 26/6/2020 · FINAL EVALUATION REPORT | Contract LHZ68 services to meet their needs (Simms, Madelyn,