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PRESENTED BY

William Arroyo, M.D.

Los Angeles County Department of Mental Health

November 6, 2012

Overview of Los Angeles Overview of Los Angeles Overview of Los Angeles Overview of Los Angeles

County Katie A. Settlement County Katie A. Settlement County Katie A. Settlement County Katie A. Settlement

ImplementationImplementationImplementationImplementation

BACKGROUND: 2002BACKGROUND: 2002BACKGROUND: 2002BACKGROUND: 2002CLASS ACTION LAWSUIT FILED AGAINST THE STATE

AND LOS ANGELES COUNTY ALLEGING:

1. Failure to assess mental health needs.

2. Inadequate mental health services.

3. Placement disruptions.

4. Over-reliance on congregate care.

5. Institutionalization—MacLaren Children’s Center.

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BACKGROUND: JULY 2003BACKGROUND: JULY 2003BACKGROUND: JULY 2003BACKGROUND: JULY 2003

� Los Angeles County entered into a Settlement Agreement resolving the County-portion of the lawsuit.

� The Settlement Agreement required the County to make systemic improvements to better serve members of the class & Federal Court appoints Katie A. Panel to monitor progress.

KATIE A. SUBKATIE A. SUBKATIE A. SUBKATIE A. SUB----CLASS MEMBERSCLASS MEMBERSCLASS MEMBERSCLASS MEMBERS

1. Are in the custody of the Los Angeles County DCFS in foster care or who are at imminent risk of foster care placement by DCFS; being considered for Wraparound, TBS, inpatient, group home (Level 10+)

2. Are eligible for services under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program;

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KATIE A. SUBKATIE A. SUBKATIE A. SUBKATIE A. SUB----CLASS MEMBERSCLASS MEMBERSCLASS MEMBERSCLASS MEMBERS

3. Have a mental disorder or condition that is documented or, had an assessment been completed, could have been documented; and

4. Need individualized mental health services to treat or ameliorate their illness or condition.

SETTLEMENT OBJECTIVESSETTLEMENT OBJECTIVESSETTLEMENT OBJECTIVESSETTLEMENT OBJECTIVES1. Promptly receive necessary individualized

mental health services in their own home, a family setting, or the most homelike setting appropriate to their needs;

2. Receive care and services needed to prevent removal from their families or dependency or, when removal cannot be avoided, to facilitate reunification, and to meet their needs for safety, permanence, and stability;

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SETTLEMENT OBJECTIVESSETTLEMENT OBJECTIVESSETTLEMENT OBJECTIVESSETTLEMENT OBJECTIVES

3. Be afforded stability in their placements, whenever possible; and

4. Receive care and services consistent with good child welfare and mental health practice and the requirements of law.

Date Action

July 2002 Lawsuit filed

August 2005 Katie A. Advisory Panel issues report finding non-compliance

October 2005 County develops Plan to Comply with Settlement Agreement

November 2006 Court orders County to make modifications to the County’s Plan

August 2007 County develops Corrective Action Plan to address Court Order

February 2008 Chief Executive Office assigned to support DCFS/DMH due to

County governance re-structure

October 2008 County develops 5-year Strategic Plan tying the original plan & CAP

together.

July 2009 Federal Court adopts County Strategic Plan

December 2011 Court approves Exit Conditions proposed by Plaintiffs and County

Timeline: County’s Settlement ProgressTimeline: County’s Settlement ProgressTimeline: County’s Settlement ProgressTimeline: County’s Settlement Progress

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Los Angeles County VisionLos Angeles County VisionLos Angeles County VisionLos Angeles County Vision

� Services are driven by the needs of the child and preferences of the family and are addressed through a strengths-based approach

� The locus and management of the services should occur in a multiagency collaborative team and are grounded in a strong community base

� The services offered, the agencies participating, and the programs generated are responsive to cultural context and characteristics

COORDINATED SERVICES ACTION TEAM COORDINATED SERVICES ACTION TEAM COORDINATED SERVICES ACTION TEAM COORDINATED SERVICES ACTION TEAM

(CSAT)(CSAT)(CSAT)(CSAT)

1. To coordinate DCFS and DMH non-line staff to rapidly receive screenings and/or referrals to ensure service linkage.

2. To integrate ‘siloed’ services and programs into CSAT through clear policies and procedures for all operational responsibilities.

3. To use a data tracking system to regularly monitor progress on indicators (i.e., timely delivery of screening, assessment, referral linkage, full utilization of resources, etc.).

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C S A T: PARTNERSC S A T: PARTNERSC S A T: PARTNERSC S A T: PARTNERSDCFS, DMH, DPH AND DPSS STAFF…

1. Children’s Social Worker

2. Service Linkage Specialist

3. Mental Health Co-Located Specialized Foster Care Staff

4. Multidisciplinary Assessment Team (MAT) Staff

5. Team Decision- Making Staff

6. Resource Utilization Management Liaisons

7. D-Rate Evaluators

8. Public Health Nurses

9. Youth Development Specialists

10. Permanency Partners Program (P3) Staff

11. Adoption Safe Families Act Staff

12. Linkages Co-Located Staff

13. Educational Liaisons

CSAT Related InitiativesCSAT Related InitiativesCSAT Related InitiativesCSAT Related Initiatives

• Mental Health Screenings by CSWs

• Determination/Triaging of Acuity

• Obtaining of MH Consent and Release of MH Information by CSWs

• Benefits Establishment

• Standardized Referral Form

• Tracking of Timelines & Service Linkage

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CASEFLOW PROCESS FOR MENTAL HEALTH SCREENING, ASSESSMENT AND SERVICE LINKAGE

Four Tracks to Four Tracks to Four Tracks to Four Tracks to

Screening & AssessmentScreening & AssessmentScreening & AssessmentScreening & Assessment

TRACK SCREENING PROCESS

Track 1

Children in newly opened cases who are detained and placed in out-of-home care receive a mental health screening at case opening.

Track 2

Children in newly opened cases under Voluntary Family Maintenance, Voluntary Family Reunification or Court-supervised Family Maintenance case plans are screened at case opening.

Track 3Children in existing cases opened before CSAT implementation are screened at the next case plan update.

AnnualChildren in existing cases are screened 12 months after screening negative

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MENTAL HEATH SCREENING, REFERRAL MENTAL HEATH SCREENING, REFERRAL MENTAL HEATH SCREENING, REFERRAL MENTAL HEATH SCREENING, REFERRAL

AND SERVICE LINKAGE PROCESSAND SERVICE LINKAGE PROCESSAND SERVICE LINKAGE PROCESSAND SERVICE LINKAGE PROCESS

REFERRAL TRACKING SYSTEMREFERRAL TRACKING SYSTEMREFERRAL TRACKING SYSTEMREFERRAL TRACKING SYSTEM

• Coordinated DCFS and DMH Electronic Referral Systems

• Office by Office Data

• Provided Monthly to Board of Supervisors

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Number of Children ScreenedNumber of Children ScreenedNumber of Children ScreenedNumber of Children ScreenedIn FY 2011-2012 regional staff reviewed 28,916 children:

� 25,026 children required screens;

� 24,745 (98.88%) were screened; and

� 18,014 (72.80%) were determined to potentially be in need of mental health services (positive).

Note: The number of children requiring screens is reduced by the number of children currently receiving mental health services, with closed cases and/or who ran

away.

Acuity of Children Screening PositiveAcuity of Children Screening PositiveAcuity of Children Screening PositiveAcuity of Children Screening Positive

In FY 2011-2012, out of 18,014 children with positive screens, DMH co-located staff determined:

� <1% children to have acute needs (to receive mental health services on the same day);

� 2.24% to have urgent mental health needs (to receive mental health services within 3 days); and

� 94.59% to have routine needs (to receive mental health services within 30 days).

Note: The number of children referred to mental health services is reduced by those with consent denied, a closed case, private insurance or who ran away.

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Children Referred for Mental Children Referred for Mental Children Referred for Mental Children Referred for Mental

Health ServicesHealth ServicesHealth ServicesHealth Services

In FY 2011-2012, out of 18,014 children with positive screens, regional staff referred 17,260 children for mental health services.

Note: The number of children with positive screens

requiring referral for mental health services is reduced by

those with denied consent, a closed case, private

insurance or who ran away.

Average Number of Days Between Average Number of Days Between Average Number of Days Between Average Number of Days Between

Screening and ReferralScreening and ReferralScreening and ReferralScreening and Referral

Out of the 17,260 children, regional staff referred for mental health services :

�Children with acute needs were referredwithin <1 day on average;

�Children with urgent needs were referredwithin <1 day on average;

�Children with routine needs were referred within 4 days on average.

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Children Receiving a Mental Children Receiving a Mental Children Receiving a Mental Children Receiving a Mental

Health ActivityHealth ActivityHealth ActivityHealth ActivityIn FY 2011-2012, children were screened for mental health needs within 6 days, on average, of case opening or case plan due date;

Children were referred for mental health services within 4 days of screening;

Children received a mental health activity within

2 days of referral to mental health services;

On average, children with positive screens received their first mental health activity within 12 days of case opening or case plan due date.

The LA CountyThe LA CountyThe LA CountyThe LA County

Children’s MH SystemChildren’s MH SystemChildren’s MH SystemChildren’s MH System� 78 Contracted Children’s Mental Health Providers

� Over 9400 Rendering Providers

� Spread across over 4,000 square miles

� $575M in Contracts

� $120M in Katie A. related Contracts

� Serve 70,000 Children Per Year

� Current Service Capacity� Over 2600 children enrolled in Wraparound

� Almost 1,200 MHSA FSP TAY slots

� 1,700 MHSA FSP Children’s slots

� 300 contracted TFC beds

� Almost 5,000 MAT assessments conducted annually

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MENTAL HEALTH SERVICE DELIVERYMENTAL HEALTH SERVICE DELIVERYMENTAL HEALTH SERVICE DELIVERYMENTAL HEALTH SERVICE DELIVERY

� Co-location of Mental Health Staff in DCFS offices� Estimating Service Capacity and Demand� Comprehensive Evaluations of New Detentions� Expansion of Intensive Home Based Services� Development of a Shared Core Practice Model� Implementation of a Quality Services Review

Process� Braiding of Funding� Penetration Rates and Costs

Key Parameters for Ensuring Key Parameters for Ensuring Key Parameters for Ensuring Key Parameters for Ensuring

Timely Access and Service QualityTimely Access and Service QualityTimely Access and Service QualityTimely Access and Service Quality

MHSA PEI ProgramsMHSA PEI ProgramsMHSA PEI ProgramsMHSA PEI Programs

� Priority Programs

� Trauma-Focused CBT

� Cognitive Behavioral Intervention for Trauma in Schools

� Child Parent Psychotherapy

� Seeking Safety

� Positive Parenting Program

� Managing and Adapting Practice

� Plus 17 EBP Non-Priority Programs

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DMH CoDMH CoDMH CoDMH Co----Located MH StaffLocated MH StaffLocated MH StaffLocated MH Staff

� 172 Staff Assigned to 19 DCFS Regional Offices (9.05/office avg.)

� Functions

� Determination of Service Acuity Needs

� Triage to Provider System

� Consultation to Children’s Social Workers

� Staffing for Various Team Meetings

� Treatment (including TF-CBT)

� Collaboration with DCFS Management

Estimating Service Demand Estimating Service Demand Estimating Service Demand Estimating Service Demand

and Capacityand Capacityand Capacityand Capacity� Negotiation with Katie A. Panel and Plaintiff

Attorneys

� Planning Numbers

� Half of DCFS children in need of MH services

� One third of those in need of intensive MH services

� Court Order for Data Sharing

� Development of Data Matching Algorithm and Katie A. Data Cube

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Multidisciplinary Assessment Team Multidisciplinary Assessment Team Multidisciplinary Assessment Team Multidisciplinary Assessment Team

(MAT) Services(MAT) Services(MAT) Services(MAT) Services

� Comprehensive Evaluation of Newly Detained Children

� Approximately 5,000 children per year

� 52 MAT providers

� Over half of children in birth to five age range

� Focus on needs and strengths

� Evaluations to be completed within 45 days

� Summary of Findings meeting

� Linkage to appropriate services/activities

Intensive Home Based ServicesIntensive Home Based ServicesIntensive Home Based ServicesIntensive Home Based Services

� Required by Settlement Agreement

� Based on Identified Needs and Strengths

� Field Capable

� Flexible Duration and Intensity

� Employ Formal and Informal Supports

� Culturally Responsive

� Integrated Services

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Wraparound ExpansionWraparound ExpansionWraparound ExpansionWraparound Expansion

� 1,200 slot capacity (2008)

� 34 Wraparound providers

� Creation of two tiers

� Case rate (Social Services) - $15K per year

� EPSDT - $27K per year

� Growth rate of 55 slots per month

� Building to capacity of 4,200 slots (now at 3000)

� EPSDT cost of over $113M

Treatment Foster CareTreatment Foster CareTreatment Foster CareTreatment Foster Care

� Shared Implementation Team

� Coordinated Contracts

� 300 Contracted Slots

� 12 Provider Organizations

� 220 ITFC

� 80 MTFC (Child and Adolescent Programs)

� MH Contract for $20K EPSDT Per Slot

� Slow Growth

� Successful Recruitment Efforts

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Core Practice ModelCore Practice ModelCore Practice ModelCore Practice Model

� Engagement of Children and Families

� Teaming

� Strengths and Underlying Needs Based Practice

� Individualized Services

� Tracking and Adapting

� Use of Formal and Informal Supports

� Transition

Quality Services ReviewQuality Services ReviewQuality Services ReviewQuality Services Review

� Intensive Case Review

� Aligned with Core Practice Model

� Systems Performance

� Client and Family Outcomes

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Early ChallengesEarly ChallengesEarly ChallengesEarly Challenges

�Teaming

�Engagement

�Voice and Choice

�Need and Strengths Based Assessment/Planning

�Long Term View

�Permanency

�Child Emotional Well Being

Braiding of FundingBraiding of FundingBraiding of FundingBraiding of Funding� TFC

� ITFC� EPSDT

� Wraparound Expansion� MHSA FSP Dollars� EPSDT (FFP, SGF, County Match)

� MAT Program� DCFS� EPSDT

� Training� County General Funds� MHSA PEI Funds� Title IV-E

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Penetration RatesPenetration RatesPenetration RatesPenetration Rates

and Service Costsand Service Costsand Service Costsand Service Costs� 75% of children with a child welfare history are

receiving mental health services

� 60% of currently open child welfare cases have received mental health services during the life of their DCFS case

� Approximately $260M/year spent by provider system for all children with a child welfare history

� An estimated $180M will be spent this year for children with open child welfare case

SummarySummarySummarySummary

� Katie A. requires fundamental systems and practice change on the part of both child welfare and mental health.

� The change must be driven by leadership committed to a shared vision and a set of principles that articulate the mission.

� Significant enhancements to current resources will be needed across a variety of organizational efforts, including program development, funding, training, coaching, and evaluation.

� Infrastructures are likely to need to be augmented to support these enhancements.

� It’s a lot of work, but it’s the right thing to do.