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

 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 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.

Transformation From group care facilities that have associated therapeutic and family permanency services To family permanency resources that have integrated residential and therapeutic services

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 transformation Step Four:Obtain financial support for the transformation effort Step Five:Select four demonstration sites who are committed to carrying out the transformation Step Six:Assist each site in developing a community-specific approach to accomplishing these changes Step Seven:Work with state entities to help them adjust the fiscal and regulatory constraints that impede transformation Step Eight:Test out initial alternative program and funding models Step Nine:Adjust models to improve effectiveness Step 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 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 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 planning during RBS post discharge Service intervention goals Projected discharge date & timeline Team decision-making Service evaluation Service delivery Program quality Evaluated by Accrediting 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 Facility quality Evaluated by Community Care Licensing 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 Comprehensive Assessment Program and Facility Quality Cost