A Systematic Approach to Meeting the Ongoing Needs of Children with Complex and Enduring Behavioral and
Emotional Disorders and their Families
A framework for a comprehensive approach to addressing the needs of a critical care population
Based on a review of research indicating the practices most likely to be associated with effectiveness
Not a single service, but a systematic approach to integrating the arc of care across multiple environments and multiple interventions
Despite important strides in service development, we have children who are placed repeatedly in high-level group homes and remain in placement for long periods of time
This subset of children have highly disrupted family relationships that have been generated in a variety of ways and exhibit complicated behavior patterns
Clinically, children and youth who experience multiple and extended high-end group home placement are distinguished by their complexity and heterogeneity
“Children manifest complex psychopathology, characterized by attachment difficulties, relationship insecurity, sexual behavior, trauma-related anxiety, conduct problems, defiance, inattention/hyperactivity, and less common problems such as self-injury and food maintenance behaviors.”
Tarren-Sweeney (2008) The Mental Health of Children in Out of Home Care. Current Opinion in Psychiatry, v. 21, pages 345–349.
The subset of children and youth with repeated and extended group home placement also put a great deal of pressure on the demand for psychiatric hospitalization
Examined from the other perspective, the children and youth who experience repeated psychiatric hospitalization also are more likely to be in group care:
A recent study found that three factors are highly related to rehospitalization:◦ living in a residential treatment facility, ◦ a diagnosis of oppositional/defiant or conduct disorder,◦ prior history of hospitalization
Rehospitalized youth were also less likely to have family involvement
Chung, W., et. al. (2008) Psychiatric Rehospitalization of Children and Adolescents: Implications for Social Work Intervention, Journal of Child and Adolescent Social Work, v.25, pages 483–496
Beyond the diagnostic criteria there are two practical characteristics of most of the children and youth in this subset:
“We don’t know what else to do” Behavior-based placement disruptions
◦ James (2008) Entry Into Restrictive Care Settings: Placements of Last Resort? Families in Society, Vol. 89, No. 3, p. 348
◦ McCurdy (2004) ‘And What About Residential…?’ Re-conceptualizing Residential Treatment As A Stopgap Service For Youth With Emotional And Behavioral Disorders. Behavioral Interventions, vol. 19, pages 137-158.
First, match the right services with the right kids and families
Most of the time, intensive in-home, day treatment or treatment foster care will be the best alternative for children with severe emotional disorders and their families
However, for the subset for whom those options are not effective, we should use short term group care as an integral component of a comprehensive response
Short-term, highly intensive group care that is multi-modal, ecological and holistic
Continuous and extensive family involvement Parallel services with the family and community
to prepare for reconnection while the child is in group care
Ongoing post-group care services to address continuing to reinforce and continue to strengthen the connection with primary caregivers, to build family resilience and protective capacity, and to address the child’s ongoing mental and behavioral health needs.◦ Hair (2006) Outcomes for Children and Adolescents
After Residential Treatment: A Review of Research from 1993 to 2003. Journal of Child and Family Studies, Vol. 14, No. 4, pp. 551–575
Make group care a part of a Re-Connection Engine
Learn to see group care settings not as places to live, but as components of an integrated, multi-environmental, multi-modal intervention designed to help children and their families achieve and maintain positive and productive permanency, despite the impact of their emotional and behavioral handicaps as well as any limitations of their primary caregivers.
Instead of raising other people’s children, find ways to help those people learn how to, and feel confident and competent in raising their children themselves.
Step One: Convene a statewide stakeholder’s group to examine the current status of high level group care in California
Step Two: Develop a framework for transforming the nature of group home services
Step Three: Gather legislative support for this transformationStep Four: Obtain financial support for the transformation effortStep Five: Select four demonstration sites who are committed to
carrying out the transformationStep Six: Assist each site in developing a community-specific
approach to accomplishing these changesStep Seven: Work with state entities to help them adjust the fiscal
and regulatory constraints that impede transformationStep Eight: Test out initial alternative program and funding modelsStep Nine: Adjust models to improve effectivenessStep Ten: Based on these results propose a statewide model
Target population Arc of Care Service Innovations:
◦ Environmental interventions
◦ Intensive treatment◦ Parallel services◦ Post-placement services
Role of the placing agency
Child and Family Involvement
Evaluation:◦ Permanency, safety, well-
being◦ Average length of stay◦ Re-entry◦ Family Connection◦ Client satisfaction◦ Utilization by county
agencies◦ Operation by the private
agency◦ Actual costs◦ Payments◦ Impact on state-county
AFDC-FC budgets◦ Impact on county MH
payments
Bay Area Consortium (San Francisco, San Mateo, Santa Clara, Contra Costa and Solano Counties) (about 100 children)◦ Children 6-12 years of age who are already in or referred to a
level 12 or 14 group home using a regional approach Sacramento County (about 24 children to start with)
◦ Children 12-16 who are in a level 12 or 14 home and are likely to continue in care indefinitely using an integrated care model
Los Angeles County (about 80 children to start with)◦ Any child who is currently in level 12 or 14 who cannot be
returned home using SB 163 wraparound alone using res-wrap San Bernardino County (about 35 children to start
with)◦ Children 14-17 who have multiple psychiatric hospitalizations
and are currently in a level 14 group home or placed out of state, using a trauma-focused, CBT model with the team following the child
AB 1453 requires each site to prepare three documents for review by CDSS prior to implementation:◦ Voluntary Agreement that describes the new care
system in detail◦ Alternative Funding Model that explains how the
new system will be funded◦ Waiver Requests to make it possible to operate
the new system
After input from a stakeholders’ group, CDSS is charged with reviewing the VAs, AFMs, and WRs to see if they meet the statutory requirements
Then CDSS has to determine if the requested waivers can and should be granted
Upon approval of the VA and AFM and granting of the waivers, a state-county MOU is created
Counties can then make arrangements with providers to begin offering RBS enrollment as an option
Sites are able to present drafts for sections of their deliverables to CDSS and the Steering Committee for iterative feedback
CDSS and its partners are working internally to prepare for the formal review process
Demonstration sites are working through local implementation teams and subcommittees to lay the ground work for implementation
Consultants prepare templates and other tools to help the demonstration sites and the state manage the design and implementation process
Everything takes longer than you would expect At this point, we are hoping to begin serving
children by July, if not sooner in some places Transformation is much more complicated than
we imagined when we started◦ Lack of easily replicated models◦ Fiscal constraints◦ Regulatory restraints◦ Newton’s first law of motion (organizational inertia)◦ Inter-system constraints
Despite this and the enormous pressure of the fiscal crisis, the local teams are plugging along with dedication and inspiration
The statute only briefly addressed the mental health component of RBS
EPSDT is a separately regulated resource, so it’s operation isn’t affected by AB 1453
This means the RBS providers will continue to use coordinated but distinct planning for the MH aspect of each child or youth’s care, based on individual needs, and in line with their local MH contracts
The target populations are already using high levels of mental health services
Utilization tends to decrease as these youth achieve permanency
RBS is available as a resource to county MH agencies
Demonstration sites must explicitly address both AFDC-FC and EPSDT funded activities in their VAs and AFMs.
The point of service integration in a multi-modal system is to use synergy and efficiency to obtain better outcomes for the same or lower costs across the board
Three agencies in each county use high end group home placements (MH, JJ, CW)
But group homes are regulated by CW Each agency accesses group homes differently Funding can be different depending on which
agency makes the placement Each county also funds group homes differently Each group home has a different way of billing
for the services it offers Each placing agency has different expectations
for the help that will be provided through placement, and in the way that it manages ongoing service delivery
If we do nothing, more than half of the children in our target populations will eventually emancipate from care, run away, enter the criminal just system or graduate to the streets
We know that as the fiscal crisis deepens the pressure for more placements will increase
We have a narrow opportunity to make a real difference in the lives of the children and families in our community who have the greatest level of need
Ultimately we want to design a resource that can be accessed quickly, consistently and reliably from multiple systems
So that we can rapidly and effectively interrupt the negative care trajectory of multiple and extended group home placements
And replace it with a positive and sustainable arc of care that anchors children with their families, and families with their communities.
Satisfaction: Youth, family, referring
agency
Youth/Family Outcomes: Safety, permanency, well-being;
Developmental progress;Improved condition/behaviors
Residentially-Based Services (RBS)
Youth/Family referred for intervention
3. Match Youth/Family Need with Program Capability:“Which RBS program can best meet child/family needs?”
Family-Based Support & Services (At Home)
Family-Based Services (Out-of-Home)
Residentially-Based Services
Locked Detention
1. Select Intervention:“What intervention best meets the needs of this child/family?”
2. Select Intervention Setting:“Where can this child/family be most successful in getting their needs met?”
Mission
Service Quality
Assess youth/family strengths & needs
Case planningduring RBS
post discharge
Service intervention goals
Projected discharge date & timeline
Team decision-making
Service evaluation
Service delivery
Prog
ram
qua
lity
Eval
uate
d by
Acc
redi
ting
Body
Management:Accountability, collaboration, communication, supervision
Staffing: Hire, train, supervise,
coach, evaluate, retain & advance quality staff
Quality improvement
Respect Child-centered
Family participation Permanent connections
Developmental focus Positive care
environment Strength-based
Reconnect youth with community ASAP
RBS
Youth at home, in school, out of
trouble
Title XXII Regs
Faci
lity
qual
ityEv
alua
ted
by C
omm
unity
Ca
re L
icen
sing
Quality Assurance:Evidence-based, promising/best
practices; program evaluation; program improvement
Values
Administration:Fiscal, program, personnel, community responsiveness
Youth enters RBS
Youth leaves
residence
After-care
services & support
Utilization Effectiveness
Cost Effectiveness
Com
preh
ensi
ve A
sses
smen
t
Program and Facility Quality
Cost