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Building Systems of Care for Juvenile Justice Youth
and Families
Idaho Children’s Mental Health Conference
Dave Gaspar
May 3-4, 2004
Boise, Idaho
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Learning Objectives
• Identify implementation of Systems of Care principles in serving Arizona’s youth and families.
• Describe lessons Arizonans are learning from their experience in implementing Systems of Care principles.
• Describe collaboration strategies necessary for successful implementation of Systems of Care principles with juvenile justice youth and families.
• Identify obstacles to serving juvenile justice youth and their families in implementing the Systems of Care principles.
• Identify opportunities and barriers in the Idaho system dealing with juvenile justice youth and families.
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Systems of Care
The concept and philosophy of “Systems of Care” has provided a guide and ongoing framework for system reform in children’s mental health.
Source Document for this information:Systems of Care Issue BriefPrepared by Beth A. Stroul, M.Ed.Published by National Technical Assistance Center for Children’s Mental Health, Georgetown
University Child Development Center in partnership with • CMHS - Child, Adolescent and Family Branch Center for Mental Health Services• SAMHSA - Substance Abuse and Mental Health Administration, U.S. Dept. of Health & Human
Services
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Major Themes of Advocates Driving System Change
1. Most children in need simply are not getting mental health services.
2. Those served are often in an excessively restrictive setting.
3. Services are limited to outpatient, inpatient, and residential treatment. Few, if any, intermediate or community-based options are available.
4. Various child-serving systems sharing responsibility for children with mental health problems rarely work together.
5. Families typically are blamed and are not involved as partners in their child’s care.
6. Agencies and systems rarely consider or address cultural differences in population they serve.
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Myths about Systems of Care
A. They are primarily designed to improve services coordination and integration.
B. They do not focus on clinical interventions but mostly focus on system infrastructure.
C. The philosophy is primarily focused on family involvement and cultural competence.
D. They are different from and/or do not involve evidence-based interventions.
E. No “traditional” services are included in them.
F. They primarily involve providing “wraparound” services.
G. They place greater value on non-professional services providers and natural supports than on other clinicians, providers, and treatment modalities.
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Defining Systems of Care
A comprehensive spectrum of mental health and other necessary services which are organized into a coordinated network to meet the multiple and changing needs of children and their families.
Stroul and Friedman, 1986.
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Systems of Care Core Values
• Services should be community-based.
• Services should be child-centered and family focused.
• Services should be culturally competent.
Stroul & Friedman, 1986 and 1996.
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Systems of Care: Guiding Principles
• Comprehensive array of services
• Individualized services
• Least restrictive and most normative clinically
appropriate environment
• Families participate in planning and delivery of
services
• Services are integrated – linkages between agencies
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Systems of Care: Principles
• Families as partners
• Cultural competence
• Interagency collaboration
• Home, community, and school-based
• Individualized strength-based care
• Accountability
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Systems of Care: Infrastructure Partners
• Child Welfare
• Juvenile Justice
• Education
• Mental Health
• Substance Abuse
• Primary Care
• Families
• Community
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Examples of Evidence-Based and Promising Treatment Models Used in Systems of Care
Approaches
• Multi-Systemic Therapy
• Functional Family Therapy
• Multi-Dimensional Treatment Foster Care
• Effective Wrap Around (Wrap Around Milwaukee)
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So - Why has it been so difficult to implement and sustain a Systems of Care approach?
• Do people simply not know about the Systems of Care Approach?
• Are the incentives inadequate?• Is there insufficient funding?• Are managed care reforms and cost containment efforts
getting the attention and support?• Is system development impeded by the lack of a pool of
qualified, committed staff?• Is our world just too complicated?• Are resources unavailable to support the effort?
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The Arizona Experience - Background
•1982 - State of Arizona requested a waiver to establish the Arizona Health Care Cost Containment System (AHCCCS) as the State entity that is responsible for Medicaid services in Arizona.
•1993 - Behavioral health services were added as a covered service within AHCCCS.
•2000 - Proposition 204 (citizen initiative) expanded Medicaid eligibility to the working poor.
•2001 - Jason K. v. AHCCCS and ADHS settled after 10 years of litigation.
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Major Themes of Advocates Driving System Change - Again
1. Most children in need simply are not getting mental health services.
2. Those served are often in an excessively restrictive setting.
3. Services are limited to outpatient, inpatient, and residential treatment. Few, if any, intermediate or community-based options are available.
4. Various child-serving systems sharing responsibility for children with mental health problems rarely work together.
5. Families typically are blamed and are not involved as partners in their child’s care.
6. Agencies and systems rarely consider or address cultural differences in population they serve.
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Arizona System Reform Leadership
• Governor established Children’s Cabinet.
• Legislators formed Children’s Caucus.
• Governor/ADHS/AHCCCS reach Jason K lawsuit settlement.
• Agency leaders signed MOU.
• MOU stipulated Executive Committee.
• Regional Behavioral Health Authorities (RBHA) accepted the charge.
• Community-based providers welcomed the challenge.
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Jason K. Settlement Agreement
Defendants: AZ Health Care Cost Containment System and AZ Dept. of Health Services - Division of Behavioral
Health Services
1. Parties intend to substantially improve the system for delivery of behavioral health services to the eligible children of Arizona.
2. Improvements contemplated emphasize partnering with families and children, interagency collaboration, and individualized services aimed at achieving meaningful outcomes.
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Jason K. Settlement Agreement
3. Implementation will require initiatives to:• Improve front-line practices• Enhance capacity of private agencies• Promote collaboration among public agencies• Develop a quality management and improvement system
4. Defendants will enter into additional agreements with:• AZ Department of Economic Security• AZ Department of Juvenile Corrections• AZ Department of Education• Administrative Office of the Courts
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Jason K. Settlement Agreement
5. Defendants agree to foster development of a Title 19 behavioral health system that delivers services according to the vision and principles set forth.
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The Arizona Vision
“In collaboration with the child and family and others, Arizona will provide accessible behavioral health services designed to aid children to achieve success in school, live with their families, avoid delinquency and become stable and productive adults. Services will be tailored to the child and family and provided in the most appropriate setting, in a timely fashion, and in accordance with best practices, while
respecting the child’s and family’s cultural heritage.”
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12 Arizona Principles
1. Collaboration with Child and Family
2. Functional Outcomes: success in school, live with family,
avoid delinquency, and prepare to live as productive adult
3. Collaboration with Others
4. Accessible, Comprehensive Service Array
5. Best Practices
6. Most Appropriate Setting
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12 Arizona Principles
7. Timeliness
8. Services Tailored to Child and Family
9. Stability
10. Respect for Child and Family’s Unique Cultural Heritage
11. Independence
12. Connection to Natural Supports
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Reform Strategy to Take Multi-level Approach• State level
• Arizona Vision/12 Principles/Q&A system• Covered services• Flex funds• Staff training/orientation
• Local level• New services integration• Standing committees• Training• New positions
• Service delivery level• Child and family teams• New partners• 24/7 family-centered access
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Defendants will take the following actions:
• Develop and implement a statewide training program
• Add respite to the list of covered services
• Devise and implement a means to contract with certified Masters-level behavioral health professionals
• Expand Title 19 services
• Create Flex Funds
• Develop practice guidelines for monitoring medications
• Initiate a “300 Kids Project” as a demonstration project
• Develop annual action plans
• Enhance the quality management and improvement system
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System Development Catalysts
• Project Match - Pima County CMHS grant
• 300 Kids Project - Maricopa County and Northern Arizona demonstration project
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ADHS/AHCCCS Annual Action PlanNov. 1, 2003 - Oct. 31, 2004
A 6-pronged strategy will be pursued with attention focused on implementation needs.
a) state level
b) local level
c) service-delivery level
1. Create sustainable and trusting partnerships with families
and other child-serving systems.
2. Develop, train, and implement effective practice
improvement protocols.
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ADHS/AHCCCS Annual Action Plan Nov. 1, 2003 - Oct. 31, 2004
3. Continue to train and coach system staff, partners, and
families.
4. Develop effective venues for barrier identification,
resolution and feedback.
5. Improve the quality management system.
6. Internalize the understanding of system reform.
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Jason K Reform Challenges
• Collaboration among formerly independent partners• Professional staff confusion of authority/role responsibility• Integration of non-professional status on child and family
teams - families and friends• Implementation as much art as science• So much so fast• Replacement of professionally directed system with a family-
directed system• Flexible funds require flexible thinking• Evolution away from medical model• Devolution of old-system power• Ambiguity of relationship between child and family teams
and legal authority
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Lessons Arizonans Are Learning
• Think big.
• Patience, patience, patience.
• Keep a face on it.
• Don’t underestimate the family.
• Think out of the box.
• Remember - it’s as much art as science.
• Keep the endgame in mind.
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Organization of Arizona’s Juvenile Justice System
Judicial branch:
• County juvenile court/probation department (15)
• State Administrative Office of the Courts - resources
Executive branch:
• State Department of Juvenile Corrections
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Arizona Juvenile Court Activity FY03
• Referrals - 75,027 (49,588 youth)
• Petitions filed - 29,537 (17,903 youth)
• Standard probation referrals - 14,454 (10,244 youth)
• JIPS referrals - 4,492 (2,432 youth)
• ADJC referrals - 1,368 (926 youth)
• Transfer to Adult Court referrals - 115 (97 youth)
• Direct files in Adult Court referrals - 526 (470 youth)
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CountyApache 282 0.57%Cochise 1,553 3.13%Coconino 1,753 3.54%Gila 923 1.86%Graham 437 0.88%Greenlee 84 0.17%La Paz 204 0.41%Maricopa 24,680 49.77%Mohave 2,218 4.47%Navajo 1,128 2.27%Pima 9,193 18.54%Pinal 2,325 4.69%Santa Cruz 702 1.42%Yavapai 1,737 3.50%Yuma 2,369 4.78%
Total 49,588 100.00%
County Juveniles Referred FY03
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Juvenile Court Reform Actions
• Created and validated new risk/needs assessment tool
• Added new mental health screening tool - MASI 2
• Renewed partnership agreements with state agencies and
local community-based mental health organizations
• Agreed to host system partner liaisons at court facilities
• Facilitated access of client data shared by all partners
• Created new policies and practices specific to mental
health youth
• Added state and local stakeholders to weekly staffing
decisions considered by juvenile court judges
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Juvenile Court Actions - Jason K Settlement
• Signed agreement to embrace Arizona Vision and
12 Principles
• Served on Executive Committee leading reform efforts
• Agreed to adopt child - family team approach
• Assisted in development of practice improvement
protocols
• Joined multi-level standing committees
• Added child-family team functions to staff responsibilities
• Arranged for training and staff development as needed
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ADJC Reform Actions
• 5 agency-wide initiatives
1) comprehensive classification system
2) diversity
3) quality assurance
4) re-entry
5) work experience
• Comprehensive Classification System
– RAC program
– CAPFA (Criminogenic and Protective Factors Assessment)
– Continuous case plan
– In-home evaluation
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ADJC Reform Actions
• Intensive specialized mental health program
• Clinical/medical personnel
– director of medical services
– chief of psychiatry
– housing unit psych staff
• Community resource centers
– family specialists
– education transition coordinators
– re-entry specialists
– voc-rehab specialists
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ADJC Reform Actions
• Parole violator assessment center
• Evidence-based programs (FFT, MST, mentoring,
therapeutic foster care)
• Annual recidivism report
• Youth Base (MIS system)
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ADJC Actions - Jason K Settlement
• Signed agreement to embrace Arizona Vision and
12 Principles
• Served on Executive Committee leading reform efforts
• Agreed to adopt child - family team approach
• Assisted in development of practice improvement
protocols
• Joined multi-level standing committees
• Added child-family team functions to staff responsibilities
• Arranged for training and staff development as needed
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Juvenile Justice Reform Challenges with Jason K
• Perceptions
• Legal vs. child and family team authority
• Deficit-based approach vs. strength-based approach
• System timeframes
• Non-traditional services
• Probation/parole officer case loads
• Collaboration expectations
• Continuity of care principles and practices
• Eligibility
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Juvenile Justice Reform Challenges with Jason K
• Interface of data systems
• Integration of treatment plan strategies
• Pooling of dollars
• Agreed-upon functional outcomes
• Family-directed emphasis
• Degree of family dysfunction
• Degree of youth dysfunction and need
• Public priorities
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Building Systems of Care for Juvenile Justice Youth & Families
• Implementation of Systems of Care principles in serving Arizona’s youth and families
• Core Values/AZ Vision• Guiding Principles/12 Principles
• Necessary collaboration strategies• State level• Local level• System delivery level
• Identifying implementation obstacles• Collaboration• Family focus
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Building Systems of Care for Juvenile Justice Youth & Families
• Lessons Arizonans are learning from their experience in implementing Systems of Care principles.
• Think big.
• Patience, patience, patience.
• Keep a face on it.
• Don’t underestimate the family.
• Think out of the box.
• Remember - it’s as much art as science.
• Keep the endgame in mind.
• Identification of opportunities and barriers in Idaho
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Arizona Contacts
• AZ Department of Health Services - Behavioral Health Division• Leslie Schwalbe - [email protected]• Frank Rider - [email protected]
• ValueOptions• Michael Terkeltaub - [email protected]
• Community Partnership of Southern Arizona• Ron Copeland - [email protected]• Jane Hedgpeth - [email protected]• Susan Olson - [email protected]
• Maricopa County Probation Department• Cheri Townsend - [email protected]
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Arizona Contacts
• AZ Supreme Court - Administrative Office of the Court - Juvenile Services Division
• Donna Noriega - [email protected]
• AZ Department of Juvenile Corrections• Suzanne Larue - [email protected]• Emily Witter - [email protected]• Alan Schwartz - [email protected]
• AZ Prevention Resource Center• Dave Gaspar - [email protected]
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Parting Thoughts
• Don’t underestimate the value and ability of the family.
• Remember - Do no harm.
