Begin with the end in mind…

Accessing effective psychosocial treatment options

Nadia Sexton, Ph.D.Casey Family ProgramsSenior Fellow to ACYF & CMS

Expectation from the top leadership:Make the Case

Enlist and align leadership with common language and knowledge

Complex Trauma:

• Complex Trauma in Children and Adolescents: White Paper from the National Child Traumatic Stress Network Complex Trauma Task Force. Substance Abuse and Mental Health Services Administration (SAMHSA, USDHHS).

Adverse Childhood Events:

• www.acestudy.org

Trauma guided child welfare system: Building Well-Being Through Trauma-Informed Child Welfare Systems

:Policy Framework

Define:• Well Being• Change Management• Case Practice and Interventions

• Fundamentals• Quality Assurance/Performance Improvement• Outcomes

• Engagement and Learning• Practice Parameters

• AACAP

New heroes may be found in the public health, early childhood, community affairs, and public works agencies in your state

Capacity of the Workforce

• Case Practice and Interventions• Fundamentals (screening/assessment, when to dx, consent protocols)• Quality Assurance/Performance Improvement• Outcomes

Define for the Child Welfare and Psychosocial/Social Services Provider Community

Check out: http://www.casey.org/Resources/Publications/pdf/MentalHealthPractices.pdf

• Uniform Assessment• Definition of youth and family engagement practices• Partnership with provider community• Partnership with your state’s higher education community

Low Hanging and High Yielding Fruit

Financing

A simple startYour state spends

money on children in programs:

• Who are they and what are they getting?

• What is the funding/contracting model?

Medicaid Expenditures for Children in Child WelfareOn average, states spend three times more for this population than for nondisabled children in Medicaid — approximately $4,336 for children in child welfare versus $1,315 for the general child population without disabilities.

R. Geen, A. Sommers, and M. Cohen. Medicaid Spending on Foster Children. The Urban Institute, Brief No. 2, August 2005. Available at: http://www.urban.org/UploadedPDF/311221_medicaid_spending.pdf.

In California, for example, Medicaid-eligible children in foster care accounted for 53 percent of all psychological visits, 47 percent of psychiatry visits, 43 percent of the public hospital inpatient hospitalizations, and 27 percent of all psychiatric inpatient hospitalizations among the program’s entire child population.

Excerpt from Testimony from John Landsverk, PhD, at Testimony to the Little Hoover Commission Children’s Mental Health in Child Welfare and Juvenile Justice, a Public Hearing on Children’s Mental Health Policy on October 26, 2000, in Sacramento, California.

A Pennsylvania study found that Medicaid mental health-related expenditures for children in foster care are nearly 12 times greater than costs for non-foster children. This study found that utilization rates, expenditures, and prevalence of psychiatric conditions for children in foster care were comparable to those of children with disabilities (i.e., children receiving Supplemental Security Income).

J. S. Harman, G. E. Childs, and K. J. Kelleher. “Mental Health Care Utilization and Expenditures by Children in Foster Care.” Archives of Pediatrics &Adolescent Medicine, 2000,154:1114-1117.

From: Allen, Kamala (2008) Issue Brief: Medicaid Managed Care for Children in Child Welfare; Center for Health Care Strategies, Inc.

$0.00

$500,000,000.00

$1,000,000,000.00

$1,500,000,000.00

$2,000,000,000.00

$2,500,000,000.00

$3,000,000,000.00

$3,500,000,000.00

$4,000,000,000.00

$4,500,000,000.00

$4,06

3,208

,171

$106

,769,0

89

$70,0

31,71

1

$30,

960,

602 $350

,972,3

23

Paid Claims 2010 Foster Youth by Servicesource: msis.ms.hhs.gov

Sum of Medicaid/CHIP

Sum of EPSDT

Sum of Home/Community Waivers

Sum of FQHC

Sum of In Pt MH <21

Financing

Consider: EPSDT

• Early• Periodic• Screening• Diagnostic• Treatment

Screening and Assessment is an entitlement to youth in the public system.

Medicaid expenditures on psychotropic medications for children in the child welfare system. Raghavan et al (2012)

http://www.ncbi.nlm.nih.gov/pubmed/22537361

RESULTS: Children surveyed in NSCAW had over thrice the odds of any psychotropic drug use than the comparison sample. Each maltreated child increased Medicaid expenditures by between $237 and $840 per year, relative to comparison children also receiving medications.

On average, an African American child in NSCAW received $399 less expenditure than a white child…………..Children scoring in the clinical range of the Child Behavior Checklist received, on average, $853 increased expenditure on psychotropic drugs.

CONCLUSION: Each child with child welfare involvement is likely to incur upwards of $1482 in psychotropic medication expenditures throughout his or her enrollment in Medicaid.

FinancingWhat is child welfare spending on now?

How about buying outcomes instead of services?

Financing

The goal is to spend on trauma informed treatments

• Trauma-Informed Treatments place a greater focus on:• Safety• Adult Support• Resilience and Protective Factors

• Trauma-Informed Treatments focus less on medications and are less stigmatizing

Making Choices: Start Here

Making Choices: Start Here

Interventions Addressing Child Exposure to Trauma: Child Maltreatment (Part 1)

Have a look: Part 1 (in draft) focuses on the comparative effectiveness of interventions that address child exposure to familial trauma in the form of maltreatment, including post-traumatic stress disorder as an outcome of interest.

Research protocol: www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=846&pageaction=displayproduct

subscribe:!: http://effectivehealthcare.ahrq.gov/index.cfm/join-the-email-list1/

Examples for Making Choices

http://store.samhsa.gov/product/Interventions-for-Disruptive-Behavior-Disorders-Evidence-Based-Practices-EBP-KIT/SMA11-4634CD-DVD

Population guided:• Disruptive Behavior

Examples for Making Choices

Provider Network Guided

Examine the data and lessons learned

Alternatives to Psychiatric Residential Treatment Facilities Demonstration (PRTF)

There is a positive effect of either maintaining or improving children’s functional outcome in juvenile justice, school functioning, substance abuse, and involvement with child protective services.”

Examples for Making Choices

Building Capacity:

The Effective Providers for Child Victims of Violence Program

Examples for Making Choices

Goal: Increase mental health professionals’ capacity to provide effective treatments to children victimized by violence.Objective: Develop a national training program to:

mobilize mental health professionals and allied professionals to embrace evidence-based trauma assessment tools and treatment models

increase the number of mental health professionals informed about and prepared to make decisions about adopting family-oriented, culturally sensitive, evidence-based treatments for children who are victims of violence

Examples for Making Choices

Core Elements for Effective Treatment

Adopt empirically-supported assessment toolsBe culturally competentAdopt evidence-based treatment modelsInvolve familiesCollaborate with other professionals and system of care

Examples for Making Choices

CurriculumBasic overview of the best available science about:Impact of exposure to violence and trauma on childrenSix Trauma-Focused Assessment ToolsFive Trauma-Focused Evidence-Based TreatmentsRole of Culture and Diversity in Victimization and TreatmentFamily-Centered, Collaborative Treatment ApproachClinician’s Self-Care

www.apa.org/pi/prevent-violence/programs/child-victims.aspxwww.Facebook.com/APAEPprogram

The California Evidence-Based Clearinghouse for Child Welfare

Places to go…

Begin with the end in mind.

Know your own landscape.

Have your data ready: youth, services, $

Find, adopt, charm, and engage partners.

Choose and step and make it.