Christina Carter, COOChristina Carter, COO

Smoky Mountain Center

December, 2012

1

General Literature Findings on

Residential Treatment

� 50,000 children admitted annually to residential facilities

� 25% of national funding supports residential placement

Why is this important to you?

2

Literature Recommendations

• Increasing resources and appropriate community

treatment would:

• Cut costsCut costs

• Allow for treatment and specific services to meet

children’s needs

• Promote treatment and service to be close to home

and incorporate support of family and community

3

The Statistics

Most Common Conditions of Children (ages 9-17)

with Serious Emotional Disturbance (5% of the population)

Disruptive Behavior Disorder 70%

Likelihood of mental health services for these youth: 40%

(Data from Great Smoky Mountains Study; Costello, 2006)

4

Disruptive Behavior Disorder 70%

Anxiety Disorder 27%

Depression 20%

Substance Abuse 16%

ADHD 13%

Research indicates:

• Gains made in Psychiatric Residential Treatment Facilities

(PRTF) do not necessarily generalize to a youth’s natural

environment

• 50% of children were readmitted to the Residential • 50% of children were readmitted to the Residential

Treatment Facility (RTF)

• 75% were with re-institutionalized somewhere or

arrested

• There is no evidence of a relationship between any

outcomes achieved in residential treatment and

subsequent functioning in the community(Friesen et al., 2001; Bickman, et al., 2000; Burns, et al., 1998)

5

The 1999 Surgeon General’s Report on

Mental Health states:

• Residential treatment centers are the second most

restrictive form of care (#1 is psychiatric hospitals)

• In the past, admission to residential treatment facilities was • In the past, admission to residential treatment facilities was

justified on the basis of:

� community protection

� child protection

� benefits for residential treatment

• None of those justifications have stood up to research

scrutiny.

6

Mercer, 2008

Community-based treatments were found to be equally or

more effective in short and long-term results, while being

less disruptive to children and families and less costly to less disruptive to children and families and less costly to

systems of care.

7

An Alternative to Residential Treatment

Facilities: Community Based Services

� Preserve the family’s integrity and prevent unnecessary

out of home placements

Put adolescents and families in touch with community � Put adolescents and families in touch with community

agencies and individuals

� Create an outside support system.

� Strengthen the family’s coping skills and capacity to

function effectively in the community after crisis

treatment is completed.

8

Restrictive vs. Intensive

� Service Restrictiveness: the extent to which youth has

opportunity to participate in natural activities in

communitycommunity

� Service Intensiveness: reflects the “dose” of the

treatment and is unrelated to the setting

� If intensive treatment is needed, community based

alternatives offer a more cost effective option.

9

What is Evidence-Based Practice?

� The term Evidence-Based Practice, used to describe a

treatment or service, means the treatment has been:

� studied, usually in an academic or community

setting;setting;

� shown to be effective;

� demonstrated in a minimum of 3 clinical trials;

� Evidence-Based Practice is the integration of the best

research evidence with clinical expertise and person-

centered values.

10

Implementation of a Community Based

Service Array

An array of community based services, implemented

with monitoring and fidelity, can serve as a robust

alternative to PRTF and other residential placements alternative to PRTF and other residential placements

for many youth.

11

Optimal Continuum Would Include:

� Outpatient Individual & Outpatient Group

� Multi-systemic Therapy (MST)

� Functional Family Therapy (FFT)

� Multidimensional Treatment Foster Care (MTFC)

12

(Surace, 2008)

The United States Department of Justice, Office of Juvenile

Justice and Delinquency Prevention, The Blueprints for

Violence Prevention Initiative, and the US Surgeon General Violence Prevention Initiative, and the US Surgeon General

all place Outpatient Individual & Group, MST, FFT, and

MTFC at the top of their lists of Evidence-Based Practices

for youth with delinquent behavior.

13

Continuum of Care

� In addition to these rigorously evaluated and empirically

supported treatments, a fully functioning continuum of

services should also include “home grown” service

approaches.approaches.

� “The most convincing evidence of effectiveness is for home

based services and therapeutic foster care” when compared to

PRTF (Surgeon General, 1999,).

� If these approaches are defined and fidelity to the model is

monitored, there is much reason to suspect that they will

bring about successful outcomes.

14

Child and Adolescent Service System

Program (CASSP) Model

�Describes effective systems of care as “a comprehensive

spectrum of MH and other necessary services, which are

organized into a coordinated network to meet the organized into a coordinated network to meet the

multiple and changing needs of children and adolescents

with severe emotional disturbances and their families.”

�This model assumes that the needs of children and

families are best served through treatment that occurs in

the least restrictive, most integrated natural setting as

possible. (Stroul & Friedman, 1994)

15

Examples of SMC’s Identified Evidence

Based Practices (EBP) Include:

� Parent-Child Interactive Therapy

� Parent Management Training

� Incredible Years� Incredible Years

� Seeking Safety

� Second Steps

� Trauma Focused –Cognitive Behavior Therapy

� Multisystemic Therapy (MST)

16

Examples of SMC’s EBPs, continued

� Family Centered Treatment

� Multi-dimensional Treatment Foster Care (MTFC)

� Adolescent Community Reinforcement Approach (A-CRA)

� Prime Solutions� Prime Solutions

� Sexual Offenders Treatment

� Response Prevention Cognitive Behavior Therapy

� Good Lives Model

� Multisystemic Therapy (MST)

17

Managed Care Organization (MCO) and

Care Coordination

Care Coordination is an administrative function of SMC that

provides:

� Identification� Identification

� Assessment

� Service Planning

� Referral and Linkage

� Monitoring

� Risk Management and Disease Management

18

What is the role of Care Coordination?

� To ensure access to the right amount, duration, and

intensity of service

� To understand the profile of children and adolescents� To understand the profile of children and adolescents

served by the system

� To help reduce escalating cost trends

19

Care Coordination: Identification

� Use Information Technology to identify target populations

and flag a need for individual care coordination, such as NC

Innovations, Special Health Care Needs and High Risk/High

Cost populations

� Referrals come from:

� Consumers/Families

� SMC departments

� Providers

� CCNC

� Stakeholders (DJJ, DSS, School, etc.)20

Care Coordination: Referral and Linkage

from Residential Treatment

When youth are in residential services and qualify for care

coordination services, the Care Coordinator:

� Participates in Child and Family Team meetings to support � Participates in Child and Family Team meetings to support

the goal of ensuring the right services in the right amount

� Assists the Child and Family Team with determining a

clinically appropriate Person Centered Plan, discharge plan

and crisis plan

� Ensures referral and linkage to an appropriate community

based provider that matches the clinical profile of the

person

21

Care Coordination: Referral and Linkage

from Residential Treatment, continued

� Ensures referral and linkage to natural supports in

community

� Ensures medical care is part of plan� Ensures medical care is part of plan

� Encourages and links adult family members and/or

guardians with services while youth in treatment and/or

services

� To provide Child & Family Teams with resources, clinical

guidance and potential Level of Care options

� Discusses Evidence Based Practices within treatment

22

Care Coordination: Monitoring

Care Coordinator:

� Monitors implementation of services to verify service

provision as outlined in Person Centered Plan

� Monitors to encourage engagement in step down

services

� Ensures access to services

� Addresses barriers to services

� Ensures services meet consumer’s needs

� Ensures back-up staffing is addressed

23

Care Coordination: Monitoring, cont’d

Care Coordinator:

� Addresses issues of health and safety

� Ensures choice of providers is offered

� Track and trend state performance measures � Track and trend state performance measures

� Short or moderate term tracking to ensure engagement in

services and stabilization

� Long term tracking and monitoring is required for

consumers with very complex behavioral health and

medical issues that result in periodic inpatient placement

despite having appropriate services and supports in place.

24

Firewall between Utilization

Management and Care Coordination

� Care Coordinator has no influence on medical necessity

determinations.

� Care Coordinator recommendations do not equal Utilization

Management (UM) approval of medical necessity.Management (UM) approval of medical necessity.

� Once a denial has been administered, Care Coordinator cannot

request additional reconsideration.

� The provider/recipient/guardian will be notified of the appeals

and denials process.

� Care Managers in the UM department treat Care Coordinators

like any other provider.

25

Firewall, continued

� Care Managers utilize information Care Coordinators enter

into the youth’s administrative database to assist in

determinations of medical necessity.

� Care Coordinators document consumer-specific information � Care Coordinators document consumer-specific information

within Alpha PIE notes as well as upload pertinent

documentation. This will include the Care Coordinator’s clinical

opinion of the youth’s service recommendations based on

strengths, needs, history and progress.

� While both departments exist within SMC MCO, Utilization

Management and Care Coordination are completely separate,

with separate infrastructure, separate supervision lines, and

are housed in separate buildings.

26

Care Coordination Contacts

To make a referral for Care Coordination, call SMC’s Access Team at

1-800-849-6127, or the local Care Coordinator Manager for your region:

Central Region (Alexander, Caldwell, McDowell)

Charlotte Bridges – 828.759.2160, ext. 3337

Charlotte.Bridges@smokymountaincenter.com Charlotte.Bridges@smokymountaincenter.com

Northern Region (Alleghany, Ashe, Avery, Watauga, Wilkes)

Maggie Farrington – 828.265.5315, ext. 4408

Maggie.Farrington@smokymountaincenter.com

Western Region (Cherokee, Clay, Graham, Haywood, Jackson, Macon, Swain)

Nancy Chastain – 828.837.0071, ext. 1160

Nancy.Chastain@smokymountaincenter.com

27

Provider Network’s Role

SMC wants to lead the system in offering Clinically

Appropriate Services.

SMC wants to Partner with the Network to develop:

� Day Treatment

� Intensive In-Home (IIH)

� Multi-systemic Therapy (MST)

� Outpatient Individual and Group Treatment

� Therapeutic Foster Care (TFC)

28

Provider Network: What to Expect…

� Development of Clinical Pathways

� Management of care to promote Clinical Pathways

� Authorizations that match clinical presentation� Authorizations that match clinical presentation

� Continue to work with consumers, families, and providers

to educate about choice and treatment

� Ensure understanding of service definitions

� Gap Analysis of services in relation to consumer profiles

� More MST, IIH, Intensive TFC, etc.

29

Provider Network: What to Expect…

� Outpatient Treatment is UNDER utilized

� Data-driven system: Outcomes for individuals and

agenciesagencies

� Better relationships

� Reductions in service on one end of the continuum to

increase services on the other end of the continuum

30

Provider Network: Tell SMC about your

agency and services!

� Schedule a meeting with SMC Provider Network:

1-866-990-9712

� Present your Evidence Based Practices

� Present your data: OUTCOMES� Present your data: OUTCOMES

� Discuss your continuum

� Development of Outpatient Treatment

� Partnerships already established or future possibilities

� What’s working and not working?

� Join Clinical Advisory Committee

� Present to SMC Provider Council

31

Comments and Questions

Thank you for attending!

Access to Services: 1-800-849-6127

www.smokymountaincenter.com

32