Jennifer Havens, MD Director, Department of Child and Adolescent Psychiatry Bellevue Hospital Center

Service System Priorities in Medicaid Redesign  Child and family-centered care in least intensive setting  Enhanced access to community-based support services for more kids  Increased flexibility to support effective care models  Increased access to preventive MH interventions in schools and primary care setting  Decreased reliance on emergency room and inpatient care

The ideal kids outpatient system  Early identification and intervention  Integrated MH services in primary care and schools  Outpatient clinics and clinic care models with capacity to provide acute care and flex to families’ needs  Community-based MH services for families who do not engage in clinic-based care  Step-up and step-down intermediate level care  Psychiatric emergency services that work for youth and families

Youth at higher levels of need in the community  Reduction in inpatient capacity – NYC lost 113 beds from 2010 to 2013  Movement to brief stabilization model of acute hospitalization  Shorter lengths of stays  Youth more acute at discharge  Whole system moving towards shorter intensive treatment periods (State hospitals, RTFs)  Reduction in RTC capacity in Child Welfare system

Increase in pediatric mental health visits to emergency departments since 1990s has persisted  Emergency Departments used as mental health safety net Nationally, 2 to 7.2% of pediatric ER visits are for behavioral health issues Less than 1 in 20 ERs have dedicated psychiatric units Most ERs struggle to meet the needs of youth in psychiatric crisis Simon & Schoendorf, 2014

What does the OPD kids system need to support the MRT Redesign and effectively meets the needs of complex youth and their families?

How do we develop a big enough and flexible enough intermediate care system?  Increase access to Partial Hospital Programs  Develop Intensive Outpatient Programs (not currently a Medicaid benefit)  Address the lack of fiscal viability of Continuing Day Treatment (need for protected educational settings a unique child issue)

Making the clinic system work for complex kids and families  How do we address workforce and fiscal issues limiting access to child psychiatry; clinic models increasingly rely on per diem staffing ?  Do we need a tiered clinic system?  What in the new benefit package can support clinics in community-based engagement strategies?  How do we develop integrated adult and child clinic models for complex families (family-based treatment)?

How do we make the clinic system work for complex kids and families?  Where do evidenced-based home-based clinical services for MH population (ie MST Psych, FFT Psych) fit in the MRT redesign?  Will Health Homes lead to better integration of case management and clinical service delivery systems?  How do we expand child clinic capacity for dual-diagnosis services (MH/SA; DD/MH)?