Acute Mental Health Care Services for Children in Pinellas County (Florida) Annette Christy, Ph.D. John Petrila, J.D., LL.M Kristen Hudacek, Psy.D. Diane Haynes, M.A. Department of Mental Health Law and Policy Louis de la Parte Florida Mental Health Institute Community Partner Personal Enrichment Through Mental Health Services Thomas Wedekind, ACSW Anne Pulley, B.S.

Acknowledgement This project was funded by the USF Collaborative for Children, Families and Communities with Funds from the Pinellas County Juvenile Welfare Board The Pinellas County specific archival data analyses were made possible by the Pinellas County Data Collaborative Portions of the Baker Act data processing and entry were funded by a National Institute of Mental Health Grant to Paul Stiles (R01MH060217)

The burden of suffering experienced by children with mental health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth. The Report of the Surgeon General’s Conference on Children’s Mental Health, Satcher, 2001, p. 3

Study Components Review of records for 35 children who had a recent Baker Act examination Archival Database Analysis Statewide Analysis of Baker Act Data Analysis of Medicaid and FL Department of Children and Families claims data Pinellas County The above sources, plus….. Additional data sources available via the Pinellas County Data Collaborative

Baker Act Examinations The Baker Act is the term applied to Florida’s civil commitment statute Individuals can undergo a short-term, involuntary psychiatric or “Baker Act” examination of up to 72-hours if: The are a person with mental illness There is evidence of harm to self, harm to others and/or self neglect Examinations may be initiated by: law enforcement officials mental health professionals judges Individuals are examined in ~115 Baker Act Receiving Facilities that are designated by the Florida Department of Children and Families

Baker Act Reporting Center Legislative reforms were implemented in 1996 in response to elder abuse related to Baker Act examinations A form documenting each examination was required to be sent to the Florida Agency for Healthcare Administration FMHI agreed to serve as the repository for these data and has been receiving data from 1997 to present These are data on short-term examination (not longer term commitment) Florida is the only state to have a central repository of client level data on short-term, involuntary psychiatric examination

Baker Act Data From 1997 to present the Baker Act reporting center has received over ½ million Baker Act examination forms. We currently receive over 100,000 forms annually This represents approximately 430 forms received on average every business day Approximately 16% of forms received are for examinations of children ~80,000 forms received documenting examinations for children from 1997 through 2002 ~17,000 forms documenting examinations for children likely received in 2003

Volume of Baker Act Data # of forms received 1997: 69,235 1998: 73,900 1999: 78,064 2000: 83,989 2001: 95,900 2002: 105,046 2003: ~109,000

Percentage Baker Act Data Adults vs. Children Statewide Data for children represented 15-17% of the data received in the past 3 and a half years

Record Reviews

Record Reviews 35 Children from the PEMHS Crisis Stabilization Unit Parent/Guardian Consented Children Assented (only after permission from parent/guardian to approach child) First two months focused on consenting only children in the foster care system Due to time and cost constraints, then attempted to consent/assent every child Review of PEMHS record for the Baker Act examination from which the child was recruited into the study

Record Reviews 40% (n = 14) of children had a history of abuse 26% (n = 9) sexual abuse 23% (n = 8) physical abuse 11% (n = 4) emotional abuse The most common presenting problem was suicidal ideation/gestures (n = 19; 54%) Just prior to their examination 80% of children (n = 28) were living with family Children had between one and four Axis I diagnoses (Mean = 2.31)

Record Reviews - Diagnoses Diagnosis N % Adjustment Disorder 15 42.86 Depression Oppositional Defiant Disorder 9 25.71 Conduct Disorder 8 22.86 ADHD Bipolar Disorder 7 20.00 Intermittent Explosive Disorder 6 17.14 Post Traumatic Stress Disorder 5 14.29 Dysthymic Disorder 4 11.43 Anxiety 1 2.86 Psychosis Schizoaffective Disorder

Record Reviews The most common referral sources were: Police 34% (n = 12) Medical Facilities 34% (n = 12)

Record Reviews The most common referral sources were: Police 34% (n = 12) Medical Facilities 34% (n = 12) 43% (n = 15) had past or current justice system involvement

Record Reviews The most common referral sources were: Police 34% (n = 12) Medical Facilities 34% (n = 12) 43% (n = 15) had past or current justice system involvement 46% (n = 16) had past or current substance abuse documented

Record Reviews The most common referral sources were: Police 34% (n = 12) Medical Facilities 34% (n = 12) 43% (n = 15) had past or current justice system involvement 46% (n = 16) had past or current substance abuse documented Insurance Status 51% Private Insurance 26% Medicaid as Primary (6% as Secondary)

Record Reviews The most common referral sources were: Police 34% (n = 12) Medical Facilities 34% (n = 12) 43% (n = 15) had past or current justice system involvement 46% (n = 16) had past or current substance abuse documented Insurance Status 51% Private Insurance 26% Medicaid as Primary (6% as Secondary) 63% Receiving TANF benefits at time of exam

Record Reviews - Medications %   DDAVP desmopressin acetate 11 31.43 Zyrtec 1 2.86 Trileptal 9 25.71 Zantac Risperidal Wellbutrin Lexapro 8 22.86 Prozac Zoloft 6 17.14 Prolixin Depakote Lithobid Strattera 4 11.43 Haldol Paxil Effexor Pamelor Cogentin Tenax 3 8.57 Avitan Seroquel Atenolol Vistaril 2 5.71 Abilify Desyrel

Record Reviews – Baker Act Data 32 children had ssn’s necessary for identification of Baker Act Data

Record Reviews – Baker Act Data 32 children had ssn’s necessary for identification of Baker Act Data These 32 children had 56 examinations over a period of almost three years

Record Reviews – Baker Act Data 32 children had ssn’s necessary for identification of Baker Act Data These 32 children had 56 examinations over a period of almost three years Certificate Type 57% (n = 32 exams) Law Enforcement 41% (n = 23 exams) mental health professional 2% (n = 1) judge

Record Reviews – Baker Act Data 32 children had ssn’s necessary for identification of Baker Act Data These 32 children had 56 examinations over a period of almost three years Certificate Type 57% (n = 32 exams) Law Enforcement 41% (n = 23 exams) mental health professional 2% (n = 1) judge Evidence Type 88% (n = 49) Harm 2% (n = 1) Harm and Neglect 9% (n = 5) Neglect 2% (n = 1) No Evidence type

Record Reviews – Baker Act Data 32 children had ssn’s necessary for identification of Baker Act Data These 32 children had 56 examinations over a period of almost three years Certificate Type 57% (n = 32 exams) Law Enforcement 41% (n = 23 exams) mental health professional 2% (n = 1) judge Evidence Type 88% (n = 49) Harm 2% (n = 1) Harm and Neglect 9% (n = 5) Neglect 2% (n = 1) No Evidence type Harm Type 66% (n = 33) harm to self 24% (n = 12) harm to self and others 8% (n = 4) harm only

Record Reviews – Baker Act Data 32 children had ssn’s necessary for identification of Baker Act Data These 32 children had 56 examinations over a period of almost three years Certificate Type 57% (n = 32 exams) Law Enforcement 41% (n = 23 exams) mental health professional 2% (n = 1) judge Evidence Type 88% (n = 49) Harm 2% (n = 1) Harm and Neglect 9% (n = 5) Neglect 2% (n = 1) No Evidence type Harm Type 66% (n = 33) harm to self 24% (n = 12) harm to self and others 8% (n = 4) harm only Repeated Examinations 1 exam 38% (n = 12) 5 exams: 3% (n = 1) 2 exams: 13% (n = 13) 7 exams: 9% (n = 3) 3 exams: 6% (n = 2) 4 exams: 3% (n = 1)

Archival Database Analyses

Archival Database Analyses 1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

Archival Database Analyses 1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence Repeated Examinations 1 exam: 67% 4 exams: 3% 2 exams: 18% 5 or more: 5% 3 exams: 6%

Archival Database Analyses 1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence Repeated Examinations 1 exam: 67% 4 exams: 3% 2 exams: 18% 5 or more: 5% 3 exams: 6% Gender: 50% Male Age: Average age at time of first examination = 13.60 years

Archival Database Analyses 1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence Repeated Examinations 1 exam: 67% 4 exams: 3% 2 exams: 18% 5 or more: 5% 3 exams: 6% Gender: 50% Male Age: Average age at time of first examination = 13.60 years Certificate Type 62% Law Enforcement 33% Mental Health Professional 4% Judges

Archival Database Analyses 1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence Repeated Examinations 1 exam: 67% 4 exams: 3% 2 exams: 18% 5 or more: 5% 3 exams: 6% Gender: 50% Male Age: Average age at time of first examination = 13.60 years Certificate Type 62% Law Enforcement 33% Mental Health Professional 4% Judges Evidence Type 89% Harm Only 5% Neglect Only 4% Both Harm and Neglect 1% Evidence Type Missing

Baker Act Exams for Children in 2002 – By Month Statewide

Pinellas County Cross System Analysis Data Set Label General Description of Data Baker Act BA A statewide database containing information about short-term, involuntary psychiatric examinations Child Welfare Data only available from July 1999 to Nov 2000 CW A statewide databases containing child (only) information on abuse allegations and demographics (founded/unfounded investigation, type of abuse and results or actions taken) Emergency Management System EMS Pinellas County-wide emergency medical service information system containing demographic and situational information on 911 calls where ambulance was sent out, whether or not someone was transported via ambulance. Department of Children and Families Integrated Data System IDS An automated data system of the Florida Department of Children and Families containing information about alcohol, drug abuse & mental health services at state funded providers. Medicaid Claims MDC A statewide database containing Medicaid physical and Mental health claims data

Pinellas County Cross System Analysis The majority of children with a Baker Act examination in the three fiscal years also had data in one of the four other data systems 18% - only Baker Act data 8% - 3 other data systems 31% - 1 other data system 14% - 4 other data systems 29% - 2 other data systems   N CW IDS MDC EMS All Children 1,559 27.33% 72.61% 40.99% Girls 778 31.75% 68.51% 38.43% Boys 781 22.92% 76.70% 43.53%

Archival Analyses – IDS Data Fiscal Years 1999, 2000 and 2001 Pinellas Statewide 41% 40% Crisis Support/Emergency 41% 35% Crisis Stabilization 18% 42% Medical Services 18% 36% Outpatient Individual 18% 19% Treatment Alternatives for Safer Communities 17% 34% In Home and Onsite Services 16% 40% Case Management 6% 25% Assessment 6% 6% Substance Abuse Detoxification 5% 17% Intervention 5% 2% Intensive Case Management

Archival Analyses – Medicaid Data Fiscal Years 1999, 2000 and 2001 % Children w/ Service Cost and % of Total Cost Pinellas Statewide Pinellas Statewide TOTAL COST FOR 3 YEARS $8.2 M $208 M 78% 61% Counseling Therapy and Treatment Services $505,000 $6.5 M 5.2% 3.1% 76% 65% Evaluation and Testing Service $155,000 $3.6 M 1.6% 1.8% 74% 57% Treatment Planning and Review $113,000 $1.7 M 1.2% 0.8% 45% 39% Targeted Case Management $1.7 M $22.8 M 17.6% 11.0% 40% 36% Children’s Behavioral Health $1.2 M $16.9 M 12.1% 8.1% 36% 28% Child Ancillary Inpatient Services $75,000 $1.8 M 0.8% 0.9%

Archival Analyses – Medicaid Data Fiscal Years 1999, 2000 and 2001 % Children w/ Service Cost and % of Total Cost Pinellas Statewide Pinellas Statewide 34% 21% Hospital Outpatient Mental Health Services $96,000 $1.8 1.0% 0.9% 33% 39% Physician’s Services $24,000 $497,000 0.3% 0.3% 26% 28% Child Inpatient Care ` $1.7M $50.0 M 17.8% 24.1% 26% 17% Other Mental Health $74,000 $894,000 0.8% 0.4% 25% 22% Emergency Mental Health Services $18,000 $1.0 M 0.2% 0.5% 24% 21% Physician’s Services Clinic or Outpatient $16,000 $497,000 0.2% 0.2%

Archival Analyses – Medicaid Data Fiscal Years 1999, 2000 and 2001 % Children w/ Service Cost and % of Total Cost Pinellas Statewide Pinellas Statewide 19% 37% Lab with Mental Health Diagnosis $4,400 $376,000 0.1% 0.2% 17% 20% Rehabilitative Services $115,391 $2.7 M 1.2% 1.3% 13% 13% Behavioral Health Overlay Services $608,057 $10.3 M 6.3% 5.0% 10% 16% Day Treatment Services $154,478 $6.3 M 1.6% 3.1% 6 % 5% Therapeutic Foster Care $1.5 M $22.3 M 15.9% 10.8% 6% 4% Substance Abuse Inpatient $156,368 $35.0 M 1.6% 1.7%

7 Key Findings

Key Finding #1 – System Findings Multiple programs are accessed by children at PEMHS The type and timing of the services are based on factors such as whether children are in the dependency system, their legal status (voluntary vs. involuntary), their needed level and type of care, and availability of services Interaction of staff from PEMHS and from the Family Continuity Program (FCP) is key to the access and continuity of care for some children

Key Finding #2 – Certificate and Evidence Type Baker Act examinations of children were more likely to be initiated by law enforcement officials and to be based on evidence of harm than examinations for adults, suggesting that a focus on factors related to law enforcement initiated Baker Act examinations would help us to better understand examinations of children and associated factors

Key Findings #3 - Seasonality The number of Baker Act examinations for children was less in the summer, both statewide and for Pinellas County Although cause and effect cannot be determined from this correlational finding, they suggest some seasonality in Baker Act examinations for children and is highly suggested that school is involved in this seasonality

Key Findings #4 – Repeated Examination Thirty-three percent of the children with a Baker Act examination over a three- year period in Pinellas County experienced more than one examination during this time period Focused attention on this subset of children with multiple involuntary examinations is warranted, given that the purpose of crisis stabilization units is to offer emergent care – not the longer term care that may be needed by many of these children Multiple examinations may suggest discontinuity of care Additional focus on this subpopulation could yield information about the causes of repeated examinations and ways to intervene to prevent them

Key Findings #5 – History of Trauma The finding that 40% or the children from the case studies had experienced sexual, physical and/or emotional abuse suggests that trauma is an important factor to address when planning and implementing care for some children who receive acute mental health care

Key Findings #6 – Therapeutic Foster Care The 41 children who experienced at least one Baker Act examination over a three- year period in Pinellas County who also had Medicaid reimbursed therapeutic foster care accounted for 6% of the children with Medicaid reimbursed services, but their therapeutic foster care reimbursed care of over $1.5 million accounted for almost 16% of the cost of Medicaid reimbursed services Almost 5% of children statewide with at least one Baker Act examination over a three-year period had Medicaid reimbursed therapeutic foster care services, at a cost of over $22 million representing almost 11% of Medicaid reimbursed services The high cost of these services for a relatively small number of children, particularly in Pinellas County compared to statewide, suggests that a focus on healthcare needs for children in this group may be warranted This may be particularly important within the current context of privatization of foster care across Florida and the focus on integration of the foster care and behavioral health care system

Key Findings #7 – Intensive Case Management The use of case management and intensive case management is lower than we expected for the population of children who had contact with the involuntary, acute-care system For example: At least one case management claim over three years: 16% Pinellas 40% Statewide At least one intensive case management claim over three years: 5% Pinellas 2% Statewide

Contact Information Annette Christy - achristy@fmhi.usf.edu - 813-974-7419 FMHI: http://www.fmhi.usf.edu Baker Act Reporting Center: http://bakeract.fmhi.usf.edu Click on “Documents” link to go to page with pdf file of complete report Collaborative for Children, Families and Communities: http://usfcollab.fmhi.usf.edu/