Eliminating Disparities In Children’s Mental Health: Improving Access in Rural Nebraska Beth Baxter, M..S. Regional Administrator Region 3 Behavioral Health Services P.O. Box 2555 Kearney, NE , ext. 222

Frontier (Less than 7 persons per square mile) Rural (7 or more persons per square mile but no associated cities of 50,000+) Metro (Cities of 50,000 or more and their associated counties) Hastings Grand Island Kearney

o Region 3 is a political subdivision of the State of Nebraska. o One of six Regional Behavioral Health Authorities in Nebraska. o Governed by elected officials, county commissioners or supervisors, one from each of the twenty-two counties that cover nearly 15,000 square miles with a population of 223,143.

o The Regional Governing Board contracts with the Nebraska Department of Health and Human Services (HHS), Division of Behavioral Health Services, for federal and state funds to provide for mental health and substance abuse services for children and adults and contracts with HHS Office of Protection and Safety to serve children and adolescents with complex needs who are wards of the state. o Region III also has entered into a cooperative agreement with the Nebraska Department of Health and Human Services, the Office of Protection and Safety, to o Counties provide local matching funds. o Region 3 utilizes these funds to: (1) manage a network of behavioral health providers; (2) provide care coordination and wraparound support for children and adolescents with serious emotional disorders and their families; (3) provide care coordination for adults experiencing psychiatric crisis; and (4) ensure the provision of mental health and substance abuse treatment, rehabilitation and support, and prevention services for those who live and work in central and south central Nebraska.

Improving Mental Health Services for Children and Families in Rural Communities o Comprehensive Community Mental Health Services for Children and Their Families Grant  Substance Abuse and Mental Health Administration, Center for Mental Health Services  Awarded October 1, 1997 ended August 31, 2003  Built upon a “promising practice”  Served a total of 1,309 children and adolescents with serious emotional disorders and their families  Sustained system of care improvements Prior to the grant we had the capacity to serve 15 youth and their families at any given time through therapeutic case management, today we have capacity to serve 348 youth and their families

Improving Mental Health Services for Children and Families in Rural Communities o Shared System of Care Vision o Involvement of Key System Partners  Children’s Mental Health Search Conference  Relationship Building  Strategic Planning Process o Strong Leadership o Community Outreach o Increase Visibility o Utilizing Promising Practices o Sharing our Knowledge, Resources, and Expertise Statewide

Improving Mental Health Services for Children and Families in Rural Communities o Commitment to Supporting a Strong Family Organization o Investment in Training and Skill Building – Cross training of system partners  Public Health  Social Service Workers  Educators  Vocational Rehabilitation o Investment in Evaluation Process o United Way 211 Line

System Partners Key System Partners Region 3 Behavioral Health Services NE Department of Health and Human Services Families CARE Supporting members of the System of Care  Providers: Community-based providers necessary to meet children, youth and families' needs.  Community: Law Enforcement, Probation, and Community Teams, Schools, Probation, and judges.

Core Values o Child and family focused o Community Based o Culturally Competent

Guiding Principles for Services in Systems of Care o Comprehensive array of services o Individualized care o Least restrictive setting o Family involvement o Service integration

Guiding Principles for Services in Systems of Care o Case management/care coordination o Early identification o Smooth transition to adult services o Rights protection and advocacy o Nondiscrimination

Desired System Outcomes  Services are managed within the budget. Efficiencies in the system of care allow for services to an increasing population at reduced cost and focus on decreasing the number of children entering state custody.  Maximizes the assets of communities and informal supports and decreases emphasis on formal service delivery.  Uses the least restrictive, least costly, most effective services, which are individualized for the child and family's needs.

 Utilizes flexible funds to meet the unique needs of each child and family.  Integrates funding, intake, assessment, care coordination, resource development, service delivery and utilization management across systems.  Produce positive measurable outcomes for children and families. Desired System Outcomes, Cont....

Characteristics of Youth and Their Families  Mental health challenges  High functional impairments in multiple areas (e.g., school, home, community, self harm, substance abuse)  Persistent problems over long-term  Multi-agency involvement  High service costs  Poor outcomes in the traditional service delivery system

Why an Individualized System of Care Approach? o Rural population…build upon community strengths, natural helpers and indigenous leaders o The comprehensive assessment identifies needs, strengths and resources o The Child and Family Team brings together natural helpers and service professionals to assist and support the child and family o Match the youth and his/her family with a Care Coordinator…skills, strengths and cultural background o Care Coordinators assist in linking families to needed services and supports and are not office based. Work with the family where the family is…work, home, community, school.

Utilizing an Individualized System of Care Approach through Therapeutic Case Management o A no reject/eject philosophy o A comprehensive assessment to determine the child and family's needs o A child and family team consisting of both professionals and natural helpers who know the child and family o A Care Coordinator, with a caseload of 1:10, to facilitate the child and family team o Care Coordinators co-located with system partners to facilitate the integration of services and share resources

Utilizing an Individualized System of Care Approach through Therapeutic Case Management o Development of an Individualized Child/Family Support Plan based on the strengths of the child and family o Strategies that are individualized to the child and family's needs and based on the family's cultural background o Through flexible funding, purchase of services and supports identified in the plan o Brokers informal resources to support families o Monitoring of outcomes and modification of strategies to produce better results

Building on Promising Practices Professional Partner Program Combines an ecological assessment and treatment planning process that utilizes the wraparound approach to coordinate supports and services for families who have children with serious emotional disorders. Works well in a rural area because of linkages to formal services and informal supports. Meets the family where they live, work, and interact within the community. Multisystemic Therapy (MST) Pragmatic, goal-oriented treatment modality that seeks to help families make changes in their child’s environment through intensive, time-limited intervention. It is an ecological model for youth with complex clinical, social and educational needs. Is provided in the home or location of family choice.

More Promising Practices… o Wraparound and MST Integration Wraparound is the primary intervention through the Professional Partner Program with MST is utilized on a selected basis as a specialized clinical treatment for specific families. The integrated process is based upon mutually agreed upon practices and procedures that include referral, assessment, implementation and evaluation. o School-Based Wraparound A team process to provide comprehensive support for families who have children with serious emotional disorders. A team of two professionals, a family facilitator and an educational facilitator, work together to implement the wraparound process in a way to facilitate the involvement of schools in the process. o Co-op for Success Is a collaborative program of Region 3 Behavioral Health Services, Grand Island Public Schools and Vocational Rehabilitation. Using the wraparound approach, the Coop provides adolescents who have serious emotional disorders with the support they need to successfully completed school and identify a long-term career goal.

More Promising Practices… o Integrated Care Coordination Unit A public care coordination collaborative that includes Department of Health and Human Services Division of Protection and Safety and Region 3 Behavioral Health Services Care Coordinators who ensure that care is individualized and managed through the wraparound process utilizing family centered practices. Youth served in the program have multiple and complex needs and are involved in the Child Welfare or Juvenile Justice system. o Early Intensive Care Coordination A collaborative program of Region 3 Behavioral Health Services and Health and Human Services that utilizes the wraparound approach to coordinate supports and services with families who are at risk of their children becoming wards of the state.

Community Wraparound o Community members work together to develop mechanisms at the neighborhood level to ensure that children and families have access to needed services and supports. o Community wraparound teams consist of a trained wraparound coordinator who facilitates the child and family team for children with serious emotional and/or behavioral challenges identified by the communities. o Community wraparound teams become the first line of defense for children and families and have access to flexible funding to assist in the implementation of individualized support plans. o Community wraparound teams mobilize informal supports that remain with the child and family far beyond the time formal services are discontinued.

Family Component Infrastructure Development and Service Delivery o Families CARE To further support families in the formalized service system a Family Partner is matched with a family served through the wraparound process.  Each Family Partner is recruited from and based within the community he/she resides.  Family Partners are parents/caregivers who have experienced the reality of raising a child with emotional and/or behavioral challenges.  The Family Partner also connects families with other families in the community and from across the region who have similar experiences and are willing to provide parent-to-parent support. o Parents for Change  Parent-to-parent support groups provide a time for families to share experiences and resources

Youth Support o YES (Youth Encouraging Support) Run by youth who experience emotional and behavioral challenges  Support  Education  Community Awareness Building  Leadership Development

The Mentor Center o Mentoring provides children and adolescents with serious emotional disorders a strength-based role model who gives unconditional support and guidance. o Youth referred to the program are matched one-on-one with a mentor who positively impacts the youth’s self esteem, school performance and social skills. o The Mentor Center participates in a coalition of “mentor-like” programs that shares training, recruitment efforts, and public relations activities. o The Mentor Center also assists communities in developing a mentor program in their community by providing consultation, technical assistance and training.

Specialized Services o Kinship Care o Post Adoptive Services and Support o Specialized Foster Care  Match youth with family of similar culture  Match youth with family who has specialized skills  Menu of services and supports based upon child’s needs o Telemedicine -- link youth and families to  Psychiatry  Bilingual specialists