OMHSAS Childrens Policy Presentation

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OMHSAS Childrens Policy Presentation

• Pennsylvania Council of Children, Youth and
  Family Services
• June 15, 2009

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For Our Discussion

• General Updates
• Budget Status Updates
• Residential Initiatives
• Continuum of Care Workgroup
• PRTF Issues, Regulations, Rate Setting
• Pay 4 Performance RTF Outcomes Indicators
• CISC Out of Zone
• Call for Change. Childrens Transformation
• Youth Family Institute High Fidelity Wrap
  Around
• School Positive Behavioral Interventions
  Supports

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Transform the childrens behavioral health system
to a system that is family driven and youth guided

• As A Reminder Major Objective Supporting
  Projects
• Call for Change Systems Transformation
• Create Home and Community Based Alternatives to
  Residential Treatment
• Develop a process for identifying and
  implementing evidence based practices promising
  practices and culturally relevant practices
• Partner with Education to support the development
  of effective school based supports and
  interventions
• Create Behavioral Health competency to honor the
  strengths and address the unique individualized
  needs of children and adolescents in other child
  serving systems
• Develop strategies to address the needs of
  Transitional Age Youth
• Better Not Well. R. Frank

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A year like none other
The economy is in a crisis not seen since the
Great Depression. Credit is frozen, consumer
purchasing power is in decline, in the last four
months the country has lost 2 million jobs and we
are expected to lose another 3 to 5 million in
the next year. Conservative economist Mark Zandi
was blunt The economy is shutting
down. American Recovery and Reinvestment Act
of 2009
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OMHSAS FY 2009-10 Budget Unified System Strategy

• Mental Health Services
• 1.014 B total state, federal and other funds,
• Net increase of 7.474 M state funds increase
  11.645 M
• Annualizes the 1 COLA (Cost of Living
  Adjustment)
• FY 2008-09 CHIPPs are annualized at 4.236, which
  includes 30 CHIPPs at Norristown and 10 CHIPPs at
  Torrance
• Increase of 1.5 M to support post-closure
  programs related to Mayview State Hospital
• Additional funding for an initiative for one HSH
  closure county
• Transfer of 335,000 to ODP for three individuals
  from the state hospitals to the waiver program
• Restores the mid- year FY 2008-09 budget
  reductions

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OMHSAS FY 2009-10 Budget Unified System Strategy

• Mental Health Services (continued)
• 2 across the board reduction, or 3.055 M, to
  county allocations
• Cut will not be applied to CHIPP/SIPP funds
• Counties may determine how to manage the funding
  reduction
• Budget does not include a COLA
• The initial initiative for Bucks County has been
  annualized
• 2nd Bucks County legislative initiative was
  removed
• No funding for services in FY 2009-10 for
  Psychiatric Services in Eastern PA

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OMHSAS FY 2009-10 Budget Unified System Strategy

• Drug and Alcohol Services
• BHSI Funding for MH and DA - 56.126 million.
• Includes state backfill of 12.107 million for
  the former IGT funding
• 2 across the board reduction of 1.145 million
• Act 152 funding is maintained at 16,227,107 for
  FY 2009-10
• Sexual Responsibility and Treatment Program (Act
  21)
• Implemented in April 2004 on the grounds of
  Torrance State Hospital
• 22 men are now being served
• SRTP program operation was transferred to the
  Commonwealth and operated by Torrance State
  Hospital (July 1, 2006)
• Special Pharmaceutical Benefit Package (SPBP)
• Increase in funding from 2.428 million to 2.835
  million

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Childrens Behavioral Health

• In FY 2006-07, there were 160,560 recipients of
  service, and Medical Assistance expenditures of
  1.275 B
• In addition, 41.5 M was allocated to County
  MH/MR programs for childrens services, including
  Student Assistance Program, CASSP Coordinators,
  Respite, and advocacy support

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OMHSAS HealthChoices

• As of January 1, 2009, there are 1.67 M people
  enrolled in HealthChoices
• Projected enrollment for SFY 2009-10 is 1.76 M (
  overall MA 2 M )
• FY 2009-10 funding projected to be 2.422 Billion
  in the Southeast, Southwest, Lehigh/Capital,
  Northeast Zone, 23 county expansion zone and 15
  county expansion zone
• Southeast Zone total 985.2 million
• Southwest Zone total 453.7 million
• Lehigh/Capital Zone total 403.4
  million
• Northeast Zone total 118.0 million
• NCSO 23 county expansion zone 182.4 million
• NCOO 15 county expansion zone 279.7 million
• Mental Health portion 2.139 billion
• Substance Abuse portion
  283.4million
• (includes admin.)

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HealthChoices Proposed Budget Initiatives

• Cost Containment Target 35M state funds
• 1) Proposal Seek return of uncommitted funds
  and unspent reinvestment funds from counties in
  HealthChoices behavioral health program.
• Current Contract language permits return of
  funds in certain instances time lags create gaps
  in commitments counties are required to seek
  Commonwealth approval to extend reinvestment
  plans.
• 2) Proposal To establish a cap on reinvestment
  up to 2 return of funds to Commonwealth in
  excess of 2 modified 3 Legacy Counties 5
  others
• Current There is currently no cap on
  reinvestment
• Reinvestment average over life of the program is
  3.5 , approximately 399M
• 3) Proposal Reduce Risk and Contingency (RC)
  from 90 days to 30 days
• 60 days for counties whose insolvency protection
  is in RC modified up to 75 days
• Current Contract allows for counties, at risk or
  who subcontract for full risk to entities
  regulated by Insurance to reserve up to 90 days
  for risk and contingency ( RC)

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Final Budget Considerations

• MCO Assessment
• Smart Pharmacy
• Senate Bill provides insight into proposed cuts
  being considered
• 500 additional million from Governors proposal
• FY 09/10 Local Integrated Solutions will be
  Imperative to sustain level of service need

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Residential Initiatives

• Continuum of Care Workgroup
• PRTF Regulations
• PRTF Rate Setting
• Quality of Care Reviews
• PPRT review of children with Mental Retardation
  within OCYF
• Pay 4 Performance Outcome Measures
• Family Involvement Best Practice
• DA Out of Zone Modification (HC)
• Secure RTFs
• Diversion from YDC

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Continuum of Care Providers

• Residential Treatment Facilities 177 licensed
  sites with approximately 4,000 beds
• 142 Accredited programs ( down from 145)
• 35 Non-Accredited programs ( down from 36)

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Utilization Rates

• The Commonwealth spent nearly 234 million on
  PRTFs (accredited facilities) in 2006.
• 6,848 kids received PRTF services between CY 2005
  and CY 2006
• Philadelphia has the highest usage Bucks and
  Montgomery had the lowest usage

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OMHSAS / OCYF Our Work Continues Continuum of
Care

• Cross Office Workgroup
• Continuum of Care Work Group
• Screening/Assessment Work Group
• Performance Requirements Work Group
• Center of Excellence (COE) Work Group
• Next Steps
• Present recommendations through regional forums
  and re-draft based on feedback
• Develop policies, protocols and timelines for
  implementation

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Mission

• Develop the statewide capability to have a core
  centralized team overseeing the vision and
  operations of regionalized State resource teams
  capable of providing youth and family-specific
  consultation to residential providers

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Recommendations

• Recommendation 1 Develop and implement program
  standards for PRTFs which go beyond the current
  platform for licensure and certification and
  advance a greater level of clinical focus and
  performance throughout the milieu. This will be
  advanced through the development and
  implementation of program performance standards
  and measures.

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Recommendations

• Recommendation 2 Given the essential role of
  family members in youths lives and particularly
  in their ongoing growth, development and success
  while in psychiatric residential care and on
  transition home, it is essential to develop and
  implement guidelines to foster family and youth
  participation in PRTF treatment. It is essential
  to develop a toolkit, which will support the
  implementation of the forthcoming Best Practices
  Guidelines for Family Involvement with Youth who
  are in Residential Treatment Facilities
  bulletin, for all stakeholders.

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Recommendations

• Recommendation 3 Develop and implement more
  rigorous, yet less burdensome Continuous Quality
  Improvement (CQI) processes. The plan is to
  begin by developing a plan for the integration of
  OCYF licensure and OMHSAS certification. This
  will be followed by a plan to include parents,
  youth, the BHMCOs and PDE Bureau of Special
  Education.

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Recommendations

• Recommendation 4 Develop and implement a DPW
  review process for requests for placement of
  youth in out-of-state PRTFs.
• Recommendation 5 Develop and implement a DPW
  process for working with families/caregivers,
  current providers and key stakeholders to bring
  youth currently in placement in out-of-state
  PRTFs back to Pennsylvania.

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PRTF Proposed Regulations

• Projected issuance as proposed January 2010
• Requires accreditation
• Rate Setting Methodology Included
• Assume rates will be rebased upon final
  regulations
• Moratorium on current rate adjustments
• HealthChoices rates rely on state rates, must
  follow rate setting policies /procedures

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Call for Change

• OMHSAS Services Retreat
• Behavioral Health Best Practices
• Evidence Based Including High Fidelity Wrap
  Around
• Promising Practices
• Culturally Relevant Practices
• Evidenced Based Practices
• Cross Systems Approach
• PCCD, OCYF, HealthChoices
• School Based Initiatives

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Pennsylvanias current youth and family service
array

• BHRS non-fee schedule program exceptions
  including
• FFT
• MST
• After school programs
• Enhanced STAP
• Services in non-JCAHO-accredited RTF settings,
  host-home/therapeutic family care settings and
  group homes
• Specific ASD-related services (Collage Program,
  Early Intensive Behavioral Intervention EIBI)
• Mental Health Services Not Otherwise Specified
  (including outpatient clinic services, MTFC, and
  mental health consultation)
• FBMHS for youth at risk of out-of-home placement
• Services in JCAHO-accredited psychiatric RTFs
• Services provided by independent licensed mental
  health practitioners
• Recognized EBP

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Practice patternsEvidence-based practices
emerging in Pennsylvania

• Multi-Systemic Therapy (MST)
• Approximately 4.0M currently in the data
  (encounter data and Alternative Payment
  Arrangements) for MST programs
• An additional 5.0M was included for MST
  expansion in CY 2009/SFY 2009-2010 rate
  development
• Functional Family Therapy (FFT)
• Approximately 125K currently in the data for FFT
  programs
• Approximately 1.3M included for FFT expansion in
  CY 2009/SFY 2009-2010 rate development

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HealthChoices statewide financial experience
2007Childrens Services All users
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Evidence-based and promising outpatient practices

• Parent-Child Interaction Therapy (PCIT) for
  oppositional young children and their parents
• Parent training programs such as The Incredible
  Years or Triple P
• Dialectical Behavior Therapy for teens with
  borderline features
• Brief Strategic Family Therapy
• Trauma-focused Cognitive Behavioral Therapy
  (TFCBT)
• Cognitive Behavioral Therapy (CBT) for depression
  and/or anxiety
• Attachment-based Family Therapy
• Multidimensional Family Therapy
• Medication management plus CBT for Obsessive
  Compulsive Disorder
• Medication management plus behavior therapy and
  parent training for Attention Deficit
  Hyperactivity Disorder (ADHD)
• Aggression Replacement Training (ART)

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Emerging school and community-based promising
practices

• HFW is currently being implemented in PA
• School-based services including
• Evidence-based outpatient satellite services in
  schools
• Cognitive Behavioral Intervention for Trauma in
  Schools (CBITS)
• Early identification of needs, reduction of
  expulsions and building of bridges to elementary
  school through mental health consultation in
  early childhood care settings
• Consultation and training with school staff such
  as Positive Behavioral Interventions and Supports
  (PBIS)
• This is currently termed School-wide PBS in PA
• It is being used in approximately 200 schools
  with plans for implementation in several more
  schools across the state including Philadelphia
  School District

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What will it take to make systems change?

• Commitment to children, youth, young adults and
  their families as active partners in their life
  plans and in our systems transformation efforts!
• Must Commit to Raising the Bar
• Moving to Evidence Based Practices
• Provider/System Implications
• Target Population
• Fidelity Tools
• Financing Mechanisms
• Credentialing
• Program Performance

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Target population Model program interviews

• Target population and eligibility criteria are
  clearly defined and strictly enforced
• One program has the certifying agency sign off on
  all admissions
• Another program has an interagency board, that
  includes a family partner, review all referrals
  for consistency with the eligibility criteria,
  including the familys willingness to have an
  intensive home-based intervention
• All programs serve different races and
  ethnicities
• Length of treatment is generally consistent with
  model program parameters
• Age ranges are consistent with EBP-targeted
  population
• PCIT targeted to children ages two to seven
• Caseload per clinician based on EBP fidelity
  standards

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Fidelity toolsModel program interviews

• Initial and ongoing training by EBP originators,
  certifying organizations or certified/trained
  consultants
• Frequent and ongoing supervision by licensed
  clinicians trained in the EBP
• Use of EBP-specific tools, protocols, outcome
  measures
• Attitudinal changes
• Willingness of staff to accept use of
  well-defined treatment approaches and protocols
• Redirection of philosophy from do for to do
  with the family
• Recognition that each family has strengths and
  reliance on the family to use their strengths
• Community preparation
• Orientation and engagement of community partners
  to the EBP tools, protocols and necessary
  attitudinal changes

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Financing mechanismsModel program interviews

• Financing fidelity to the EBP model
• Additional EBP costs can be built into rates and
  specialty services codes
• Grants (federal, State, county dollars) and more
  flexible funds (such as reinvestment) usually
  fund start up, training and initial evaluation)
• Juvenile justice and child welfare agencies often
  fund the start ups
• Medicaid funds individual components when the
  child or family is Medicaid eligible
• Fundraising must supplement ongoing operations,
  training, supervision and equipment
• Decreases in fidelity related to decreased
  funding
• PCIT uses walkie-talkies instead of ear buds to
  comment on parent-child interactions observed
  behind two-way mirrors

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Credentialing Model program interviews

• Staff credentials
• Specific to EBP
• All staff meet mastery or certification (as
  required by EBP) and participate in ongoing
  training and supervision
• Wraparound program emphasized importance of
  selecting a high-fidelity practice model (e.g.,
  Wraparound Milwaukee)
• Profession not as important as personal
  flexibility
• Willingness to follow the EBP protocols and use
  tools
• Family and youth partners
• Generally participants and graduates of the
  programs

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Program performanceModel program interviews

• Most providers have internal quality improvement
  program plus quality initiatives with
  training/certification agencies
• Some EBPs involve certifying organization (MST)
  or training center/center of excellence (PCIT)
  for independent fidelity analysis
• EBP outcomes include
• High completion rates
• Positive impact on family functioning
• Reductions in out-of-home placement (juvenile
  detention, foster care, inpatient psychiatric),
  reductions in recidivism/arrest
• Improvements in psychiatric status and decrease
  of substance abuse
• Mainstream school attendance if possible
• Positive cost benefits

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As a reminderOur work in the coming year

• General
• Implement FY 09/10 Budget Strategies
• Expand Incident Reporting Process/ Root Cause
  Analysis
• Implement Drug and Alcohol Coalition
  Recommendations
• Develop technical assistance for MH Procedures
  Act
• Develop statewide communication strategy/
  implement Network of Care
• Begin State Plan Changes
• Children
• Implement Early Adoption of Wrap Around
• Implement CISC Out of Zone
• Call for Change for Children
• Assist with Autism transition with commercial
  insurance
• Issue Residential Treatment Regulations
• Forward School Based Positive Practices PEPS
• Take steps to build continuum of services for
  OCYF/JJ and behavioral health
• Strengthen service array for Young Adults

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Our work in the coming year

• Adults
• Strengthen Peer Initiative approve additional
  training and specialized curriculum, including
  forensic peer specialist training, Older Adult,
  MY/MR
• Implement Supported Housing Focus Technical
  Assistance for development of Fairweather Lodges,
  CRR conversion
• Focus State Plan Changes ACT, Psych Rehab, Drug
  Alcohol
• Continue Service Area Planning
• Monitor Federal Rule Changes
• Criminal Justice Agenda/ Center of Excellence
• Older Adults
• Strengthen Older Adult Peer Initiative
• Strengthen Letters of Agreement between Aging/
  SCA and MH/MR
• Support MFP
• Additional Training/support to BH and Aging
  Coalition

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RESOURCES..

• Resources
• parecovery.org
• www.OlderPennsylvanians.org
• pa-co-occurring.org
• www.networkof care.org
• Service Delivery Specific to County
• Library of Resources
• State and Federal Legislation
• Local, State and National Advocacy Efforts
• Secure Personalized Features
• Interactive Features

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With Challenge Comes opportunity for Growth !!!

• Growth is the process of responding, positively
  to change. Grappling with hardships, trouble and
  calamity, facing adversity in a spirit of
  determination and courage loving and not being
  crushed by broken hopes holding our head high,
  having done our best---- this is growth

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You Are The Evidence !!!!!!

• Im The Evidence
• For how belief inspires
• How hope transforms and
• How giving heals the soul
• Im The Evidence
• For what can be achieved
• How feeling connected can ground and
• How there is invaluable worth in an act of faith
• Im The Evidence
• For how an example can lead
• How far encouragement can take you and
• How one step begins a journey towards endless
  possibilities
• 2008 Transformation Designs

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OMHSAS Contacts

• Dr. Mary Diamond, Medical Director
• [phone]
• Stan Mrozowski, Director, Childrens Bureau
• [phone]
• Aidan Altenor, Director, Bureau of Hospital and
  Community Operations
• [phone]
• Linda Zelch, Director Western Operations
• [phone]
• Sherry Snyder, Director Eastern Operations
• [phone]
• Thomasina Bouknight, Southeast Community Program
  Manager
• [phone]
• Mike Orr, Northeast Community Program Manager
• [phone]
• Julie Barley. Central Community Program Manager
• [phone]
• Valerie Vicari , Western Community Program
  Manager
• [phone]