1. Advances in Community Mental Health Treatment Presented By: Chris Morano Ph.D., Wraparound Milwaukee

2. What is Wraparound Milwaukee  A system of care organized to provide comprehensive services and supports to children and adolescents with serious emotional and mental health needs and their families  It is organized as a special managed care entity publically operated by Milwaukee County Behavioral Health Division under the 1915a provisions of the Social Security Act, which allows it to function as a type of HMO for a distinct Medicaid population within a specific geographical area (Milwaukee County)  Current enrollment is approximately 900 youth/families with 1400 families served annually

3. Specific Populations Wraparound Milwaukee Serves  Youth with a DSM-IV diagnosis  With a more chronic condition likely to require services for a year or more  Currently or previously served across two or more child serving systems i.e. Child Welfare, Juvenile Justice, Mental Health, special education  At imminent risk of placement in a :  Residential treatment center  Psychiatric hospital  Juvenile correctional facility

4. Programs Operated by Wraparound Milwaukee  Mobile Urgent Treatment Team – crisis intervention services in Milwaukee County including dedicated teams with Child Welfare  Regular Wraparound – court-involved youth (600 youth)  FOCUS – Corrections Alternative(Collaboration with DCS/WM/St. Charles  Re-Entry – youth with SED transitioning from DOC ( Collaboration with DOC and DCS)  Healthy Transitions (Project O’YEAH) – 16 ½ to 24 youth/young adults transitioning to adulthood  REACH – Wraparound Program for voluntary referrals (230)  FISS – diversion from Child Welfare for status offenders ( 60 youth/families)

5. Characteristics of Our Population  72% Boys  71% African American, 17% Caucasian, 9% Hispanic  Average Age 14  Status at enrollment in Wraparound Milwaukee  46% Delinquent  20% CHIPS  6% JIPS  28% None (voluntary REACH families)  Top Diagnosis:  Conduct Disorder  ADHD  Depression/Mood  AODA  Learning Disorder  Psychotic

6. Daily Youth Served in 2010- Delinquency order Targeted Monitoring Program (n=105) Systems of Care Integration Model “Wraparound Milwaukee” (n=430) State Juvenile Corrections (n=190) Diversion (n=200) Daily Average Youth Under DCSD/DOC ~ 2040 Pending or Community Probation

7. Philosophy of Care and Approach to Delivery Care and Services to SED Youth/Families  Strength-based  Highly individualized to meet specific needs of child and family  Comprehensive – We provide whatever services are needed and “wrap” around family’s needs  Family directed using child and family teams  Community-based – emphasis is on treating child in community while maintaining community safety  Collaboration across systems – develop a single care plan  Culturally competent  We don’t easily Give-up on any child

8. Components of Wraparound Milwaukee Program  Screening and Assessment  Care Coordinator  Mobile Crisis  Family Advocacy  Provider Network/Comprehensive Benefit Plan  Clinical Oversight  Quality Assurance  IT/Program Evaluation  Fiscal Management

9. How We Pool Funds CHILD WELFARE Funds thru Case Rate (Budget for Institutional Care for Chips Children) JUVENILE JUSTICE (Funds Budgeted for Residential Treatment and Juvenile Corrections Placements) MEDICAID CAPITATION (1843 per Month per Enrollee) MENTAL HEALTH CRISIS BILLING BLOCK GRANT HMO COMMERCIAL INSUR WRAPAROUND MILWAUKEE CARE MANAGEMENT ORGANIZATION (CMO) 46.5 M CHILD AND FAMILY TEAM PLAN OF CARE 10.0M 19.5M7.0 M CARE COORDINATION PROVIDER NETWORK 210 Providers 80 Services

10. Wraparound Milwaukee’s Comprehensive Service Array Behavioral & Clinical Services – Crisis intervention Individual therapy Intensive in-home therapy Evaluation Substance abuse therapy Medication management Day treatment Placement Services Acute hospitalization Foster home and treatment foster home Group home care Residential treatment Crisis/residential, group, Level 4 FC Supported independent living Other Supportive Camps After school and Suspension accountability Transportation Interpretive services Equine/animal therapy Consultation with other professionals Supportive Services Mentors, tutors Crisis 1:1 stabilizer Parent/family aide Life coach – independent living Employment preparation and placement Job – internship Respite Crisis/planned respite Residential respite Service Coordination Care Coordination Discretionary Clothing Food/groceries Housing assistance Child care Furniture, appliances YMCA membership Educational expenses

11. Outcomes for Wraparound Milwaukee  Financial – average cost per month:  Wraparound Milwaukee is $3700  $9000 in DOC, over $9000 in RCCCY/month and over $10,000 7 days psychiatric hospital  Programmatic – Milwaukee County population in RCCCY dropped from 375 to 90 youth; drop in DOC population resulting in closure of two state facilities, reduction in psychiatric inpatient beds from over 250 to 50 beds  Clinical – improved functioning based on CBCL (Achenbach)  Recidivism – most recent study of 669 delinquent youth enrolled in Wraparound Milwaukee for a period of 15 months showed a 15.2% rate of reoffending. Among 210 “high risk youth” i.e. juvenile sex offenders, etc. the rate was even lower at 6.7%  Child Permanency – 75% of youth were in permanent setting with parent, relative, adoptive resource or subsidized guardianship

12. State Corrections

13. Is Wraparound Milwaukee an Evidence-Based Practice?  There are at least 10 studies currently supporting Wraparound as a EBP (National Wraparound Initiative NWI – lists on web-site)  We believe in Evidence Informed Approaches versus EBP’s  We don’t buy off the shelf programs ie. MST, etec  We look at innovative approaches and “best practices”  Adapt to our community circumstances and characteristics of our population  We measure overall impact on our youth/families through established outcomes measures  Market forces usually drive families to utilize providers and services who are more innovative, get better outcomes and provide a better quality service

14. MUTT Team Crisis Intervention for all youth Crisis group home/beds, inpatient gatekeeping 2 Clinical Psychologists, 20 Social Workers, Psychiatric Nurse, consulting Psychiatrist MUTT FF, MUTT TFC, Crisis stabilizers Outcomes HFS 34

15. Trauma Informed Crisis Intervention… Based on Trauma Informed Care (Perry, 2009) Effects of trauma, neglect also seen when emotions high Neurosequential Therapeutic Assessment and response

16. Therefore…Neurosequential Therapeutic Response Inconsistent/absent/abusive early relationships = distressed, anxious, destructive youth who…..live limbically in primitive part of brain Move from self-regulation- relational- cortical/cognitive/verbal strategies

17. Therefore, therapy with traumatized, complex needs/disorganized youth… In early stages = aimed at primitive part of brain = soothing, reorganizing Music, movement, massage, balance.. NOT at the higher level functions, like speech – they’re not “ready”

18. “Therapy is two people in a room, one of whom is more anxious than the other ”

19. ..it’s immensely difficult to do.. Crises traumatize staff, and, yes, in the immediate moment.. Easy to lose it out there > Brain hijacking = 3 Types of people……

20. So, just like managing a toddler’s TT… These kids have power, and are terrified by it, especially if you are. Undereact to everything Act “As if..” Be nurturing, repetitive, calm, and attentive to non- verbals!

21. Ethical and Boundary Challenges in the Community The good The bad The enticing….

22. Normalizing… Temper tantrums Disagreeability Defiance, anger Need for immediate gratification Laziness, avoidance, etc. Likes things you don ’ t like (eg., music) Even thoughts of death, suicide

23. The Challenges of Family/consumer choice.. Wraparound core value Italy and the neighborhood

24. The Ethics of… Diagnosis Medication

25. The Ethics of Solutions..What helps??? 2005 Milwaukee study APA 2006 Report SAMHSA Findings Favor Systems of Care DC Interagency Forum + Milwaukee Data = Serious crime way down Drinking, smoking, teen pregnancy down

26. So… …what’s next?