1. Services provided by Mercer Health & Benefits LLC Office of Mental Health and Substance Abuse Services Children’s Advisory Committee Residential treatment facility research and data overview October 17, 2008 Andy Keller, Boulder Peter Selby, Seattle

2. 1 Mercer Current residential capacity in Pennsylvania  3,038 in-state accredited residential treatment facility (RTF) beds as of September 1, 2008 (versus 3,223 in October of 2007)  1,309 non-accredited RTF beds  Non-Medicaid beds: – Youth development centers: 4 facilities, 696 beds – Secure care: 9 facilities, 267 beds – Secure residential: 4 facilities, 98 beds – Juvenile detention centers (JDCs): 22 facilities with 870 beds  What does it mean that 1,700 youth per year from other states use Pennsylvania RTF facilities?

3. 2 Mercer What kind of transformation is needed?  Goals related to RTF for transforming the behavioral health system for youth: – Reduce reliance on RTFs  This will require enhancement of community capacity  This will require a reduction in RTF capacity – Intensify and improve the quality of the treatment in RTFs.  This will require improved quality standards for RTF care across the board – standards that are enforced  This will require development of specialized RTF capacity for key groups: trauma, young women, youth with aggressive behavior, co-occurring substance use and mental health needs – Bring youth back to their communities from out of state, as well as from distant out of community placements – Make family involvement a fundamental component of RTF services

4. 3 Mercer Can the strategy be statewide, regional or county-level?  It must be county-level because local systems of care vary widely in their needs, available services, and strategies  It must be regional because smaller counties will need to share some specialized capacity  It must be statewide because the funding and standards to drive the transformation require that scope  Bottom line: It must be an integrated strategy encompassing all three levels

5. 4 Mercer Example one: Residential treatment facility service use patterns vary at the county level  2005 – 2006 patterns of RTF service by Child in Substitute Care (CISC) / non-CISC are stable at multi-county level  But there are major differences at the county-level Use under 60 days/over 365 days 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% StatewideHealthChoicesExpansionAlleghenyPhiladelphia CISC under 60 daysNon-CISC under 60 days CISC over 365 daysNon-CISC over 365 days

6. 5 Mercer Example two: Diagnoses of residential treatment facility users also vary by county  Same pattern of CISC/non-CISC diagnoses is seen at each level of analysis  But there are major differences in proportion at county-level Primary diagnosis – CISC versus non-CISC 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% StatewideHealthChoicesExpansionAlleghenyPhiladelphia Conduct disorder (CISC)Conduct disorder (Non-CISC) Mood disorder (CISC)Mood disorder (Non-CISC) ADHD (CISC)ADHD (Non-CISC) Adjustment disorder (CISC)Adjustment disorder (Non-CISC)

7. 6 Mercer Will require new rate structure  Evolution of rate structure over time – Historically, there had been cost-based methods to develop rates – With the statewide implementation of managed care, there has been less focus on cost-based reimbursement with rates more subject to negotiation – Current rates are low, creating pressure to limit quality of care and sell capacity to other states at higher prices – There is now a need to develop cost-based methodologies for targeted new RTF modalities and partner with providers and behavioral health managed care organizations (BHMCOs) to implement them

8. 7 Mercer Infrastructure for new rate structure  New RTF regulations include a review of the fee-for-service (FFS) rate setting – New FFS rate structure can serve as a benchmark for BHMCO rate setting – BHMCOs have historically used FFS rates as a reference point for their rates  The new structure should include: – A base rate for all accredited RTF care – Differential rates to be paid in addition to the base rate for each of the areas of specialization prioritized by OMHSAS – Development of a process to engage RTF providers in transformation efforts, including inclusion of performance incentives

9. 8 Mercer Essential to define the need for residential treatment facility capacity at the county and regional levels  Important to carry out needs assessment to determine appropriate capacity for basic and specialized RTF services: – Will require a collaborative process involving the Department of Public Welfare (DPW), Office of Children, Youth and Families (OCYF), OMHSAS, counties, BHMCOs, families, and key stakeholders in each county – Determine each county’s need for RTF capacity in each area of specialization identified by the service array subgroup  Transformation will require reductions in current RTF capacity and more RTF specialization – Without reductions, beds will continue to be filled even if community options are expanded – Increased costs to deliver enhanced RTF care and expanded community services will require offsets

10. 9 Mercer Need to set standards to enhanced continuum of RTF  Standards would be developed for the following areas of specialization: – Specialized residential programming:  Gender-responsive services  Secure RTF  Other specialized programs, including treatment for co-occurring mental health (MH)/developmental disability, autism spectrum, co-occurring MH/substance abuse – Placement options that vary by intensity and focus:  Extended sub-acute stabilization and evaluation  Family-based RTF (30 – 60 days, fewer beds)  Longer-term intensive and restrictive RTF  Small group homes in community (non-RTF)

11. 10 Mercer Examples of success from other states  In many ways, Pennsylvania must be a leader on this initiative – No other state that we know of has the amount of existing RTF capacity that OMHSAS has – No other large state has fully implemented a similar statewide strategy – That being said, we can learn from the experiences of other states and RTF providers

12. 11 Mercer Examples of success from other states  Oregon cut its RTF use in half through policy changes and changes to the RTF referral process – Without any new funding, the State, in partnership with stakeholders, significantly enhanced capacity to track resources and outcomes – Oregon also targeted improved services at the local level, using evidence-based practices – State administrative rules were rewritten to make sure all clinical procedural codes needed were in place and care coordinators were accessible in each community – The State used policymaking and purchasing to leverage changes focused on increasing family voice across all levels – Success was seen in changes in the role of family members, the location of services and type of services provided

13. 12 Mercer Examples of success from other states  New York is in the early stages of a transition driven by their Office of Child and Family Services that will: – Establish criteria to access services that include standardized assessment tools (Child and Adolescent Needs & Strengths), integrated use of evidence-based practice, and requirements to expand community-based services – Commit $620,000 per year to the operation of a statewide evidence-based dissemination center that has already trained; over 400 clinicians in trauma-focused cognitive behavioral therapy

14. 13 Mercer Examples of success from other states  Individual RTF providers have successfully transitioned from large institutional models to family-based group home, therapeutic foster care, mobile crisis and stabilization services and wraparound-based community approaches: – Two programs in California:  Hathaway-Sycamores Child and Family Services  EMQ Children and Family Services – The Drenk Center in New Jersey

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