Report of the Childrens Workgroup Florida Commission on Mental Health and Substance Abuse

1
Report of the Childrens WorkgroupFlorida
Commission on Mental Health and Substance Abuse

• Co-ChairsHonorable Jeri Cohen, MiamiJohn
  Haines, Ed.D., TallahasseeCommission
  MembersPatricia Holmes, M.S.Representative
  Sandra MurmanLaura SchuckBob SharpePhyllis
  Sloyer, MPAStaffBob FriedmanMary Ann
  KershawDebora Simmons

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Methods Used By Workgroup

• Meetings
• Five Meetings Held in Conjunction with Commission
  Meetings
• One Special All-Day Meeting Held on Financing
• Material Reviewed
• Testimony to Overall Commission
• Presentations to Workgroup (14 presentations were
  made by invitation)
• Florida Statutes, Reports, and Other Documents
• Reports and Documents from Other States,
  Professional Organizations, and Federal Level
• Individual Discussions
• Consultant on Financing

3
Findings Prevalence Incidence

• Mental Health
• 10 with serious emotional disturbances
• 20 with diagnosable disorder

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Substance Abuse

• (from Florida Youth Substance Abuse Survey, 2000)
• Use Within Past 30 Days
• High School Students
• 43.4 alcohol
• 18.3 marijuana
• Middle School Students
• 20.4 alcohol
• 5.1 marijuana

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Special Populations

• Foster Care 75 with mental health and/or
  substance abuse problems
• Juvenile Justice about 100,000 Florida youths 10
  to 17 (7 of total population) are referred for
  delinquency each year 60 have emotional
  problems, 36 have serious substance abuse
  problems, and 20 have a serious mental disorder
• Substance Abuse 50 of adults in substance abuse
  system have children
• Child Protection 80 of children in child
  protection system have parents with mental health
  and/or substance abuse problem.

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Preschool Children

• 9 in two to five year age range with serious
  mental health problems
• Increased attention to parent-child relationships
  during infancy
• Greatly under-served population

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Co-occurrence of Mental Health and Substance
Abuse Problems

• Of youngsters treated for substance abuse
  disorders, 80 to 85 also have a mental health
  disorder
• Of youngsters with co-occurring disorders, in
  83.5 of the cases the mental health disorder was
  first, in 3.7 they occurred at same time, and in
  12.8 of the cases, the substance abuse disorder
  was first (from National Comorbidity Study)
• Yet, there is a lack of integrated treatment, or
  even consistent cross-system training

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Long-Term Consequences Need for Preventive
Efforts I

• Early onset psychiatric disorders have been
  associated with subsequent truncated educational
  attainment, higher risk of teenage childbearing,
  higher risk of early marriage, lower probability
  of late marriage, and lower family income
• R. Kessler, based on National Comorbidity Study
• Early onset disorders tend to be more severe and
  disabling than later onset disorders
• R. Kessler

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Long-Term Consequences Need for Preventive
Efforts II

• Report to the Commission by Alan Leshner,
  Director, National Institute on Drug Abuse
• If we can prevent the use of illegal substances
  before an individual reaches young adulthood,
  then the likelihood of an adult substance abuse
  disorder is slight

10
Resources I

• Many public agencies with important role in
  childrens mental health and substance abuse, and
  numerous funding streams
• Inadequate resources
• Fragmentation in planning, funding, and service
  delivery
• Lack of accountability at the system level
• High level of unmet need (DCF-supported MH/SA
  system presently serves about 23 of children in
  need of MH services and 14 of children in need
  of SA services).

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Behavioral Health Funding Streams for
Children Families in the Public Sector

• MEDICAID
• Medicaid Inpatient
• Medicaid Outpatient
• Medicaid Rehab. Svcs.
• Medicaid EPSDT

• MENTAL HEALTH
• MH General Revenue
• MH Medicaid Match
• MH Block Grant

• EDUCATION
• ED General Revenue
• ED Medicaid Match
• Student Services

• SUBSTANCE ABUSE
• SA General Revenue
• SA Medicaid Match
• SA Block Grant

• OTHER
• TANF
• Childrens MedicalServices
• Mental Retardation/Developmental Disabilities
• Title XXI
• Local Funds

• CHILD WELFARE
• CW General Revenue
• CW Medicaid Match
• IV-E
• IV-B
• Adoption and Safe Families Act

• JUVENILE JUSTICE
• JJ General Revenue
• JJ Medicaid Match
• JJ Federal Grants

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Resources II

• Absence of insurance (either public or private)
  constitutes significant barrier to access to
  treatment, and to choice of provider.

13
Resources III

• Considerable concern about reimbursement rates
  for services under Medicaid. Special concern
  expressed about Behavioral Health Overlay
  Services (BHOS).

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Resources IV

• In 1990s, Florida has shifted to greater reliance
  upon Medicaid funding and less on general revenue
  funding. However, it does not appear that Florida
  is fully realizing the potential of Medicaid yet.
  In particular, match from public school systems
  and local government agencies may have potential
  for significantly leveraging funds, and use of
  IMD waiver to include residential substance abuse
  services may also help.

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Childrens Budget
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Childrens Substance Abuse Federal Funding
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Systems of Care I

• General consensus that integrated,
  community-based systems of care represent
  approach to be taken in serving children with
  severe behavioral health challenges.
• For example, the Surgeon Generals Report on
  Mental Health indicates that, the multiple
  problems associated with a serious emotional
  disturbance in children and adolescents are best
  addressed with a systems approach in which
  multiple service sectors work in an organized,
  collaborative way.

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Systems of Care II

• The best treatment programs provide a
  combination of therapies and other services to
  meet the needs of the individual patient from
  Principles of Drug Addiction Treatment A
  Research-Based Guide, National Institute on Drug
  Abuse.

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Systems of Care III

• Within both mental health and substance abuse
  systems, Florida has strong statutes that call
  for the establishment of such systems
• However, resources to assist communities in
  developing such systems has not accompanied the
  statutes, and while Florida has a number of
  communities with promising efforts, much more
  work is needed to develop and evaluate
  collaborative systems.

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Case Management with Flexible Funds

• Consistent support for the recommendation of Dr.
  Martin Cohen to the Commission that, in serving
  individuals with complex problems, it is
  essential to develop a single point of
  responsibility and accountability for each
  consumers care give that person the authority
  to get the consumer what they need when they need
  it.
• Some excellent examples of this in Florida but
  additional work to develop effective systems of
  case management with flexible funds (often called
  wraparound) is needed in order to develop
  systems of care that provide individualized care.

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Specialty Mental Health System
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Provider Network

• Acknowledged to be a key to an effective system
  of care
• While there are many excellent providers (both
  organizationally and individually) in Florida,
  concern was expressed about the general need to
  add more providers to the network, and to
  strengthen the capacity of existing providers to
  offer high quality individualized care.

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Prevention

• Consensus is that strong prevention efforts are a
  key to long-term progress
• While there have been considerable resources
  invested in prevention, particularly in the
  substance abuse, juvenile justice, and child
  protection systems, there is not a
  well-coordinated, comprehensive, integrated
  prevention effort with multi-system planning.

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Fiscal Incentives

• A major part of an effective system is the use of
  fiscal incentives to promote system goals and
  objectives. Concerns were raised about the manner
  in which such incentives are currently used in
  the system.

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Information and Referral

• Need for strong information and referral services
  was strongly identified, particularly by parents
  who are not sure where to turn when they first
  suspect that help is needed
• Florida has launched a collaborative mental
  health-substance abuse effort to provide
  information and referral services
• This was started without any additional
  resources.

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Screening

• Absence of routine screening procedures to detect
  special social and emotional needs of children
  within systems such as primary health care, child
  care, and education
• These are the systems that have the opportunity
  to identify children at a point in time when
  intervention can be more cost-effective.

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de facto Mental Health/Substance Abuse System
All Children
Family
Neighborhood
Prevention
UniversalServices
Primary Healthcare
Child Care
School
Developmental Disabilities
SpecialHealthcare
JuvenileJustice
SpecialEducation
Shelters
ChildWelfare
de facto Mental Health/Substance Abuse System
Mental Health Substance Abuse
Specialty Mental Health/Substance Abuse System
28
Families

• Families are becoming increasingly more involved
  both at the system and service planning level.
  However, there is a long way to go to adequately
  involve families, and particularly to incorporate
  family choice into the service system.

29
Diversity

• Census data indicate that the population in
  Florida is becoming increasingly diverse. Yet
  there is a general absence of attention to racial
  and ethnic diversity in planning and delivering
  services.

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Local Infrastructure and Capacity

• It is acknowledged that effective service
  delivery requires an adequate infrastructure and
  capacity at local and state level. However, a
  consistent concern was expressed about a
  perceived declining capacity at the local level
  to plan and manage the system both because the
  system is becoming increasingly more complex, and
  number of staff at the local level is not growing
  to keep up with the need.

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Accountability

• Florida has been one of the most proactive states
  in developing an outcome-based accountability
  system. However, present system needs to be
  re-examined to determine if proper measures are
  being used, and to develop procedures to put the
  information that is gathered to use to strengthen
  the system and improve care.

32
Information Systems

• Effective system management requires strong
  information systems. Yet, concerns were expressed
  that existing systems currently fail to provide
  the data needed for system management and
  monitoring, and for collaboration between
  agencies.

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Vision for the System

• Based on discussions within the Workgroup,
  presentations to the overall Commission, review
  of state statutes, and lessons learned from
  presenters to the Workgroup and articles about
  characteristics of effective systems.

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Vision for the System

• Designed to be able to provide individualized,
  and family-centered services within communities
• integrated at the service delivery level so that
  comprehensive services can be provided
• integrated at the policy/system level so that
  resources are accessible at the practice level in
  the manner that they are needed without
  categorical barriers
• accountable for quality of care at the practice
  level, and accountable for overall system
  performance

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Vision for the System

• with strong family involvement at all levels
• responsive to needs of diverse communities and
  populations of children and families
• with emphasis on promotion of health and
  well-being and prevention of problems, as well as
  treatment
• with wide range of home and community-based
  options for children and families

36
Vision for the System

• with coordination and collaboration in planning,
  funding, and service delivery between systems,
  especially mental health, substance abuse,
  dependency, delinquency, education, physical
  health, and child care
• with case managers/service coordinators who work
  closely with children with the most complex needs
  and their families to provide support to them and
  to ensure that the needed services are provided

37
Vision for the System

• with a community that is educated about the needs
  of children and families, with the result that
  stigma is reduced and barriers to entry into care
  are reduced
• with all families having access to needed mental
  health and substance abuse services
• with families having reasonable choice about
  providers and services
• with information systems that provide the type of
  data needed to effectively manage and continually
  improve a complex system

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Vision for the System

• with a focus on strengths of children and
  families as well as problems
• with a strong developmental perspective,
  providing appropriate promotion, prevention, and
  treatment services across the developmental cycle
  for children, beginning with the youngest of
  children and including children making a
  transition into adulthood
• with a large and diverse provider network.

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Recommendations

• What Do We Need to Do to Reduce the Discrepancy
  Between our Findings and our Vision?

40
Recommendations

• At the practice level, Florida should ensure that
  there is a strong case management system in place
  with flexible funds and reasonable caseload
  sizes, and a well-prepared provider network so
  that children with the most complex needs and
  their families can receive individualized and
  comprehensive services

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Recommendations

• At the policy/system level, ensure that the
  structure provides the resources for coordinated,
  individualized care. This includes moving to
  blended or pooled funding, to the use of lead
  agencies and administrative service organizations
  (in large communities) to share responsibility
  for system development, and service delivery
  (including the case management function), and to
  promote accountability

42
Recommendations

• Ensure joint planning among program, policy and
  funding agencies responsible for mental health
  and substance abuse services, the child welfare
  system, the juvenile justice system and the
  school system

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Recommendations

• Develop a greater multi-systemic emphasis on
  promotion of well-being and prevention, and a
  stronger focus on the needs of young children.
  There should be an ongoing multi-system effort to
  develop appropriate health promotion, prevention,
  and early intervention activities

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Recommendations

• Continue to support community-level planning and
  system management. This should include developing
  the local capacity and leadership through such
  mechanisms as strengthening use of information
  systems, expanding opportunities for technical
  assistance, and ensuring adequate staff to
  innovate as well as plan and manage complex
  systems

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Recommendations

• Seek new state, federal, and local funding to
  respond to high level of unmet need, and to bring
  about needed system change explore ways to
  expand federal funding, such as use of local
  match for Medicaid, expansion of the Medicaid
  program in the schools, and the support of the
  IMD waiver for residential substance abuse
  services explore ways to use existing funds more
  effectively through collaboration, pooled
  funding, and proper use of fiscal incentives.
  Also, review reimbursement rates for services
  provided under Medicaid

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Recommendations

• Build on the philosophy included in Chapters 394
  and 397, and particularly included in the
  establishment of pilot system integration
  programs in four districts for childrens mental
  health, and in two districts for childrens
  substance abuse. The state should provide funding
  for implementation of the approach expressed in
  Chapters 394 and 397, thereby not only addressing
  inadequate resources but also creating fiscal
  incentives to develop collaborative,
  community-based systems of care that provide
  individualized, family-centered services

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Recommendations

• Provide needed funding for strong information and
  referral systems, and establish communications
  campaign to educate general public about nature
  of behavioral health issues in children, and how
  to access services

48
Recommendations

• Increase the involvement of parents of children
  with behavioral health problems in state and
  local policy and planning

49
Recommendations

• Ensure that systems are responsive to the needs
  of children and families from diverse racial and
  ethnic groups

50
Recommendations

• Recognize the importance of the de facto
  behavioral health system, institute consistent
  screening procedures for behavioral health
  problems with the de facto system, and develop a
  training and communications campaign specifically
  targeted at de facto system

51
Recommendations

• Ensure that all children have either public or
  private insurance coverage for behavioral health
  services, and that the benefit provides for an
  appropriate range of services

52
Recommendations

• Create mechanisms for independent study and
  evaluation of promising innovations around the
  state so that communities around the state can
  benefit from the innovations. These studies
  should examine new system of care developments,
  changes in financing and contracting, specialized
  courts, expanded involvement of families, and new
  types of collaborations.