Challenging Behaviors in Challenging Times:How We Can Best Serve Children through Multi-Agency Collaboration

UNDERSTANDING OUR SYSTEMSWilliam Arroyo, M.D.

Regional Medical Director, Los Angeles County Department of Mental Health

December 7, 2010

MISSIONEnriching lives through partnership designed to strengthen the community’s capacity to support recovery and resiliency

New Strategic Plan (6-10-10)GoalsEnhance the quality and capacity

of mental health services and supports in partnership … within available resources

Eliminate disparities … especially those due to race, ethnicity and culture

Enhance the community’s emotional and social well-being…

…with a workforce capable of meeting the needs of our diverse communities

Maximize fiscal strength…Use of research and

technological advancements…

DMH Nos. At A GlanceNo. of outpatient clients: 209,386 (FY 08-09)No. of inpatients: 15,879 (FY 08-09)Avg. daily no. of clients in adult justice

programs: 2300No. clients served in juvenile justice

programs: 15,954 (FY 08-09)No. of clients with Public Guardian: 2800No. of calls received by ACCESS: 283,098Crisis field evaluations: 19,000 served4 Urgent Care Centers (24 hr): 11,000

served

At A Glance - 247 directly-operated programs130 contracted agencies112 potential new contractor agencies89 pharmacies27 fee-for-service hospitals3 indigent hospitals338 fee-for-service individuals4 contracts/MOU’s with veteran’s organizationsBudget of $1.58 billion (gross appropriation) (FY

09-10)

New Treatment StrategiesShort termFocused (especially around crisis, trauma,

depression)Evidence basedExpansion of community based

approachesExpansion of in-home strategiesExpansion of crisis resolution approachesIntegration with primary care

Main Sources of Childrens MH FundingRealignmentMedi-Cal Managed CareEPSDT (a Medi-Cal program) includes

Therapeutic Behavioral Services, Day Treatment, Day Rehab, Outpatient

Healthy Families: basic & SED MH benefitAB 3632Mental Health Services Act: FSP’s and PEISpecialized Foster CareFamily Preservation

EPSDT (Medical Necessity Criteria)Below age 21Mental disorder results in at least one of

following:(1) significant deterioration in key

domain (2) probability of significant deterioration in key domain or

(3) a probability of not progressing developmentally

Medical Necessity Criteria - 2

Condition is not responsive to general medical interventions

(Outpatient) Intervention would: (1) significantly diminish impairment; (2) prevent significant deterioration in key

domain; or (3) allow child to progress developmentally

Meets the criteria of one of the following Dx:

ELIGIBLE DIAGNOSESPervasive

Developmental Disorders (including Aspergers D and excluding Autistic D)

Disruptive Behavior DFeeding/Eating D of

Infancy and Early Childhood

Elimination DSchizophrenia/

Psychoses

Mood DAnxiety DSomatoform DFactitious DDissociative DParaphiliasGender Identity DEating D

ELIGIBLE DIAGNOSES -2Impulse Control DAdjustment DPersonality D, exc. Antisocial Personality

Disorder

Mental Health Services Act Proposition 63—a California voters’ ballot initiative

—passed in 2004 Based on recovery/wellness Stakeholder involvement Focus on unserved and underserved

1% tax on personal income in excess of $1 million intended to expand mental health services

5 components Community Services and Supports, Workforce

Education and Training, Capital/Technology, Prevention/Early Intervention, Innovation

Outcomes – Increase: Likelihood of having a safe place to liveHaving meaningful use of time

(e.g., school, work, training).Having supportive relationships with family,

friends, and neighbors.

Outcomes – Reduction of:SuicideIncarcerationSchool failure and dropoutUnemploymentProlonged sufferingHomelessnessRemoval of children from their homes

FULL SERVICE PARTNERSHIPS The FSP program is for children ages 0-15 or TAY

ages 16 – 24 and their families who would benefit from a program designed to address the total needs of a family whose child or youth is experiencing significant emotional, psychological or behavioral problems that are interfering with their wellbeing.

FSP programs are capable of providing a wide array of services beyond the scope of traditional clinic-based outpatient mental health services. Those participating in a FSP program will have the support of a service provider 24 hours a day, 7 days a week.

Children’s Programs (0-15) Full Service Partnership - (“high

end children”)

Priority populations (1) children removed or at risk of removal from their families,

(2) children experiencing extreme behaviors at school (3) children involved with Probation and families affected by substance abuse

Transition Age Youth Programs (16-24)Full Service Partnerships – (“high end”

youth) Priority Populations

(1) youth with substance abuse disorders, (2) youth who are homeless or at risk of becoming homeless,

(3) youth are emancipating from DCFS & Probation,

(4) or youth leaving long term institutional care, experiencing first psychotic break

FULL SERVICE PARTNERSHIP SERVICES (0-15, TAY)

24/7 clinic/field-based/in-home that include multi-discipinary teams for crisis intervention & assess

Culturally competentIndividualizedSocial/recreational/faith-basedEngagement with ethnic minorities

through schools/primary care clinics/shelters

WraparoundTrauma specific servicesCommunity re-entry services (juvenile

halls & camps)

FSP Services (0-15, TAY) (cont’d)TransportationInteragency collaborationRespite CareProbation halls/campsGLBT specificMH Services & Supports

for caregivers/parents, including crisis family services

Temporary/permanent supportive housing

Co-Occurring Disorders Services

Drop-in Center Services (TAY)

FSP – TAY only

Peer partnersSupport for independent livingBasic living skillsIntegrated MH with law enforcement

agencies

Requirement of Full Service Partnership (LACDMH)Programs may not discriminate against

individuals with a mental illness who have co-occurring disorders, including individuals with physical health problems, developmental delays, low literacy issues, substance abuse issues, or other issues.  Rather, providers must demonstrate the ability to collaborate with other Departments or entities (e.g., Regional Center, DHS) in order to ensure clients access the services most appropriate for their needs and to which they are entitled.

MHSA Prevention and Early Intervention (PEI) Priority Populations

Underserved Cultural Populations Individuals Experiencing Onset of Serious

Psychiatric Illness Children/Youth in Stressed Families Trauma-Exposed Individuals Children/Youth at Risk for School Failure Children/Youth at Risk of Juvenile Justice

Involvement

Priority Child/Youth Population (indigents) multi-dimensional definition

Severe emotional/behavioral crisisIn or at risk for out of home placement Certain diagnostic categoriesSevere functional impairment

OPERATIONAL AGREEMENT BETWEEN L.A. CO. and REGIONAL CENTERS (2005)

Chief Administrative OfficerDepartment of Mental Health Probation DepartmentDepartment of Children and Family ServicesSeven Regional Centers (in L.A. County)

“AGREEMENT”State regulations indicate that “regional

center funds shall not be used to supplant the budget of any agency which has a legal responsibility to serve all members of the general public and is receiving public funds for providing those services”

Agreement is “…to meet the needs of persons with developmental disabilities who are also mentally ill”

GOALS OF AGREEMENT (pertaining to LACRC’s and LACDMH)

Increase leadership, communication…To optimize utilization of agency

resources…To decrease costs and minimize fiscal

risk…To ensure continuity of services…Improve quality outcomes…Strive toward highest client

functioning…in least restrict settingTimely resolution of conflicts…

AGREEMENT - OUTPATIENTLACDMH and LACRC’s will develop and

implement…general plan for crisis intervention…shall include after-hours emergency response systems, interagency notification guidelines and f/u

If psychiatric care is warranted, both will develop procedure for a client based on the presenting dx and medical necessity, as defined by State regulations. Once the client no longer requires MH treatment, the client is referred to LACRC for f/u

AGREEMENT - INPATIENT RC clients admitted to psychiatric

inpatient facilities due to a mental disorder will be the responsibility of LACDMH. LACDMH will provide psychiatric treatment until there is no further medical necessity for acute inpatient care. Discharge shall occur when medical necessity criteria are no longer met. If placement by RC is delayed, the client is placed on administrative days for which RC’s are responsible beginning on the 5th administrative day.

CA CODE OF REGULATIONSTitle 9, Chpt 11, Section 1830.205

Los Angeles County DMH will meet the needs of Regional Center clients/consumers who meet medical necessity criteria as in CA code

Persons eligible for developmental disability services referred to LACDMH for mental health services will receive an evaluation and assessment to determine the extent of their need for services. LACDMH will provide appropriate mental health services…

Critical Challenges & IssuesFunding for indigent careEmergency response capacity given ER

overcrowding & limited long-term care options Katie A. lawsuit (children in foster care)Implementation of MHSA components of PEI,

WET and Innovations Needs of youth in juvenile justice system, i.e.

halls & campsAB 3632 fundingHealthcare reformWorkforce issues

ResourcesLos Angeles County DMH website with MHSA info., list of mental health agencies, other

MH linkshttp://dmh.lacounty.gov

Los Angeles County DMH Medi-Cal Network Providers (Psychiatrists and Psychologists)http://dmh.lacounty.gov/cms1_054947.pdf

Los Angeles Network of Care provides an online service directory, i.e. addiction, disability insurance, housing, emergency shelter (by zip code)

http://losangeles.networkofcare.org/mh/home/

Los Angeles County Guide to Medi-Cal MH Services http://dmh.lacounty.gov/cms1_046410.pdf

Healthy Familieshttp://www.healthyfamilies.ca.gov/hfhome.asp

CA State DMHwww.dmh.ca.gov

Resources (cont’d)CA Mental Health Planning Council’s Master Planhttp://www.dmh.ca.gov/MHPC/masterplan.asp

Characteristics of the uninsured:http://covertheuninsured.org/media/research/brffs.pdf

Report from the President’s New Freedom Commission on Mental Health

http://www.mentalhealthcommission.gov/reports/reports.htm

Healthy People 2010 report – Mental Health Sectionhttp://www.healthypeople.gov/Document/pdf/Volume2/18Mental.pdf

California Little Hoover Commission Report On Mental Health, Being There: Making a Commitment to Mental Health Nov. 2000

http://www.lhc.ca.gov/lhcdir/report157.html