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This briefing paper defines a proposed project to expand and support the diagnostic and intervention strategies available to Hawaii's youngest children prenatally exposed to alcohol and drugs.
Citation preview
The Children’s
Behavioral Health
SMART Model of Care
Ensuring Access to Earliest Intervention for
Hawai‘i’s High-Risk Children Birth Through Five Years
Ira J. Chasnoff, MD
GG Weisenfeld, EdD
2 | P a g e
The Children’s Behavioral Health SMART Model of Care
The purpose of this report is to describe the outcome of a one-year community-
based planning process to develop a model of behavioral health care for
Hawai‘i’s children, ensuring that all high-risk children birth to five years of age
throughout the state will have full access to early identification, comprehensive
assessment, and a full range of therapeutic services.
The SMART Model of Care has been developed through a partnership between
Hawai‘i Community Foundation and Hawai‘i’s State Departments of Health,
Human Services, and Education as well as the Zero to Three Courts, the Health
Care Transformation team in the Office of the Governor, and the Hawai‘i
Primary Care Association. The Model of Care represents the dedicated work
and leadership of these agencies.
What do we know? The early years are the most important. We know this much is true: the first
few years of children’s lives are vital for their ultimate growth and
development. During this time, the basic difficulties that define life-long mental
health, developmental, and learning problems can begin to emerge.
We also know that a child’s development is a dynamic process, involving both
social and biological factors that contribute to success or failure. From day one,
the child interacts with the surrounding environment and seeks the nurturing
support that will help him achieve full potential for growth and development.
Thus, behavioral health problems can emerge from a wide variety of biological
and environmental factors. Just as premature birth, prenatal exposure to
alcohol or drugs, or poor maternal nutrition can harm fetal brain development,
family violence, substance abuse in the family, or maternal depression can
interfere with the child’s brain development after birth. The problems that
emerge as the child enters school leave the child unprepared for learning.
Right now in Hawai‘i, children who need early intervention for developmental
and behavioral health problems are not identified until they are older; the best
opportunity to help them has been missed. Experienced professionals point
out that many children are struggling in school with problems that could have
been addressed much earlier. Others point to children who get in trouble with
the law and know that their difficulties could have been identified much earlier
in life and steps taken to help them avoid developing serious and perhaps life-
long problems.
Children with developmental or behavioral health problems who are identified
early in life and receive the services they need have a better chance to develop
to their full potential – at home, in school, as an employee and as a citizen.
However, the human benefit to the child is not the only benefit. Families benefit
when children are helped early on in life because this avoids school difficulties
and behavioral problems. Schools benefit - ask any teacher about the
3 | P a g e
disruptions in the classroom due to children who have difficulty controlling
their behavior. The foster care system will benefit if there are fewer
placements needed to find a child a home. The State benefits from having more
children functioning well in the normal settings of life and fewer occupying
Dependency Court, Special Education classrooms and the corrections system.
The benefits are both human and financial.
“High-risk” children are those children who have exposure to risk factors that
are known to lead to problems in living. For example, children born to mothers
who used tobacco, alcohol and/or illicit drugs during pregnancy are at risk for
developing developmental and behavioral problems. Exposure to domestic
violence, poverty, neglect and abuse are other risk factors that add to the
complexity of life for many of Hawai‘i’s children. An estimated 20% of children
in the US have a diagnosable behavioral health condition, and about 2%-5%
suffer from a serious behavioral health disorder that causes substantial
impairment in functioning at home, at school, or in the community.1 There is no
reason to think that these numbers do not apply in Hawai‘i.
There are social and fiscal ramifications for society when children are not
identified early and provided appropriate care. These children typically
display more aggressive and disruptive behavior that places them on a
trajectory associated with a range of negative life outcomes in youth and early
adulthood.2 On the other hand, when children are identified as needing
behavioral health services early and receive the appropriate care, they are3:
Less likely to receive psychiatric inpatient services [savings of $1,433
per day4]
Less likely to visit an ER for behavioral and/or emotional problems
[savings of $165 per visit5]
Less likely to be arrested [savings of $4,142 per month per child6]
Less likely to repeat a grade [$10,736 per child7]
Less likely to drop out of school [$41,369 per youth8]
Less likely to be arrested as a juvenile [$5,656 per arrest9]
More likely to remain in a foster care placement [savings of $1,790 per
month per child10]
Children with serious behavioral health conditions incur costs in multiple
child-serving systems, including mental health care costs, MEDICAID, TANF,
high school drop out costs, and child welfare costs. Colorado calculates that
early intervention produces a reduction of 40% of projected future
expenditures, making the Return on Investment (ROI) $1.80 per each dollar
spent on children under the age of 511.
Hawai‘i’s children are at risk for severe problems of developmental,
behavioral, mental health, and social/ emotional functioning due to a wide
range of factors (Kids Count Data Center, 2014; HYIPR Report FY 2013,
DHS/CWS Annual Progress Report, 2014):
• 1,542 children were low birth weight (8.1% of total births)
4 | P a g e
• 101 children died by age one (2011)
• 46% of children entering foster care entered by age 5
• 893 children were in foster care under the age of 5 in 2013
• Over 700 young children were confirmed abused/neglected in 2013;
46% were under 1 year of age
• 3.5% of infants and toddlers participated in Early Intervention [majority
for speech/language]
The planning process Responding to the issues facing children and families in Hawai‘i, Hawai‘i
Community Foundation (HCF) led the effort to develop a Model of Care for
high-risk children throughout the state. HCF organized a team of state leaders
from the public and private sectors to assess the current status of children in
Hawai‘i, examine departmental and agency approaches to a variety of factors
that impede appropriate behavioral health development, and develop an over-
arching strategy to promote the early identification and treatment of high-risk
children and their families. The team reflected a public-private partnership and
crossed organizational and professional boundaries:
Hawai‘i Department of Health
o Family Health Services Division
o Children with Special Health Needs Branch
Hawai‘i Department of Human Services
o Child Welfare Services Branch
o Med-Quest Division (Medicaid)
Hawai‘i Department of Education
Hawai‘i Zero to Three Court, Family Court, First Circuit
Health Care Transformation Project, Office of the Governor
Hawai‘i Primary Care Association.
Governance of the planning team was guided by a core set of principles agreed
to by all team members.
1. The Leadership Group:
a. is a voluntary collaboration between interested public and
private/community sector stakeholders
b. can add representatives of other stakeholders by consent of the
group
c. is not a governmental body and is not subject to Sunshine Laws
2. The Leadership Group:
a. provides leadership to advance the group’s vision and mission
b. makes recommendations to:
a. improve access to and quality of behavioral health services
to children ages 0 to 5 years old in Hawaiʻi
b. coordinate between agencies/entities to eliminate gaps
and duplication of services, leverage available funding
more effectively, and create smoother, more effective
5 | P a g e
transitions between caregivers for children needing
services and their families.
c. holds each other accountable for forward progress to achieve
agreed goals
3. Duration:
a. Anticipated life span of the Leadership Group is 3 to 5 years,
unless terminated sooner by the members of the group
b. Frequency of the meetings and progress goals/milestones are to
be determined by the group.
4. Authority of the Leadership Group:
a. The Leadership Group has the authority to convene meetings, set
agendas, decide meeting procedure, amend these ground rules,
and terminate the existence of the Leadership Group
b. The Leadership Group has no authority to make any decisions for
any of the agencies/entities represented in the Leadership Group.
Each agency/entity retains its own independent authority to make
decisions about and implement the recommendations of the
Leadership Group.
5. Decision-making process:
a. Decisions of the Leadership Group preferably will be made by
consensus. However, the Leadership Group may decide to have
specified agenda items decided by a vote of individual members.
b. Decisions of the Leadership Group are recommendations only
and are not binding on the member agencies/entities belonging
to the Leadership Group.
c. Silence = acquiescence. In other words, members who say
nothing about an agenda item are assumed to be in agreement
with the decision of the group.
d. A written record of decisions by the Leadership Group may be
retained for internal use of the group and for individual member
organizations to understand and implement recommendations.
6. Governance structure:
a. The Leadership Group may create subcommittees or other
advisory groups to work on specific topics or tasks as directed by
the Leadership Group, consisting of designated staff from each
department or entity represented in the Leadership Group and
other experts and stakeholders by invitation.
b. Any such subcommittee or other advisory group shall be subject
to these ground rules.
c. All recommendations from all subcommittees and advisory
groups shall be subject to final review and approval by the
Leadership Group.
6 | P a g e
7. Record-keeping and confidentiality:
a. The meeting discussions, meeting materials and notes, and
related emails and communications:
a. are for the use of members of the Leadership Group and
their respective staff
b. are not intended for publication or dissemination outside
the Leadership Group unless approved in advance by the
Leadership Group
b. Formal meeting minutes and record keeping are not required.
Each member is expected to keep his or her own records of the
meetings and materials related to the work of the Leadership
Group.
8. Role of the Hawaiʻi Community Foundation
a. To convene and facilitate meetings of the Leadership Group
b. To support the work of the Leadership Group with research and
analysis at HCF’s option, including support for the research and
advisory work provided by Dr. Ira Chasnoff and GG Weisenfeld
as contractors of HCF.
Theoretical Framework The specific aim of this initiative is to build a system of care through which all
children in Hawaiʻi birth to 5 years of age have access to the interventions and
therapeutic services they need to support the children’s achieving their full
potential.
Shared values
A core set of shared values shape the planning team’s thinking:
• Systems improvement must reflect the needs of children and their
families, be simple, and be easy to access.
• Statewide access is vital.
• The system needs to embrace cultural practices and place value on
cultural diversity and competence.
• Early Intervention, especially before the age of 6, benefits children the
most.
• Evidence-based practices provide the best opportunity for improving
outcomes of children and families.
• Financial sustainability will be built on primary and secondary payors
and on public and private sector financial support.
• The system will not be dependent on individuals within departments, but
will survive change in leadership over time.
Definitions
Based on these values, it was recognized that successful early childhood
development must be defined as broadly as possible. Behavioral health
encompasses social, emotional, behavioral, and relational development as well
7 | P a g e
as motor, speech and language, etc. Thus, as we seek to identify and intervene
with all children at risk in Hawaiʻi, this broad definition guides our thinking.
It also was recognized that children can be found throughout the community,
not just in specific, narrowly defined settings. Thus, a second task was to take
a broad view of children’s lives in Hawaiʻi, considering the narrow gates where
children gather throughout the islands. These narrow gates include places
where medical, social service, and educational services are provided, as well
as other community-based primary sites of contact in which children can be
found.
Community-based is the preferred term for the approach taken because it
places a special emphasis on the breadth of the effort. It is not narrowly
medical, though it depends heavily on the community’s physicians and other
health care providers. It is not a public health initiative alone, though the role
of public health professionals and outreach workers is essential. It is not driven
by mental health treatment, per se, but does recognize the importance of
quality treatment capabilities throughout the community. It is not powered by
the authority of the courts, though the effort would be missing an enforcement
element if the courts were absent. Similarly, the business community, the
church community, the schools all have a stake in the success of the effort and
will play an important role. The important point is that the authority of the
approach comes from the broad base upon which it rests and in which it is
rooted.
SMART: The Core Intervention
SMART is an acronym that stands for screening, decision-making, assessment,
referral, and treatment.11 It is the “core intervention” that the planning process
sought to establish in the community.
Screen Screen all children for behavioral health risk. Largely this is
accomplished by becoming a fixed part of primary health care for
pregnant women and children’s primary health care as well as
outreach into multiple narrow gates around the community.
decision
Making
Make a decision within the primary screening site as to whether
immediate early intervention will provide the support and services
the child needs or whether the child needs to move to higher levels
of intervention.
Assess Those children who screen positive are given an appropriate level
of assessment to determine service and intervention needs.
Refer Those children who require higher levels of care are referred up
through a linked and integrated system.
Treat Those children who are referred to each level of intervention and
treatment receive quality, evidence-based treatment that is
appropriate for the child’s and family’s circumstances.
8 | P a g e
Levers of change
One of the team’s first steps in the planning process was to identify and then
prioritize the top 3 levers of change to implement the system:
Establishing a joint goal, “vision statement” to which all are committed
Map interventions available at each level of the system, examining
issues of
o Coordination
o Accessibility
o Screening and earliest intervention
o Costs across total system
Examine and resolve barriers to data sharing
o Federal definition
o Lack of data system
o Consent process as needed
o Standardization of screening tools
Research and Investigation for Background Information The team’s work was supported by data and information collected through a
variety of surveys and investigation of existing public and private agency
services, policies, and procedures.
Site visits
In January 2015, the Hawai‘i Community Foundation sponsored site visits to
three programs developed through a similar planning process and successfully
operating SMART systems of care:
• Cradle to Crayons [Phoenix, AZ]
• MCSTART [Monterey, CA]
• Desert Mountain Children’s Center [Apple Valley, CA]
Cradle to Crayons (C2C) is housed in the Arizona County Judicial system and
serves children birth to three years in the foster care system. Three renovated
buildings connected to the courtrooms offer space for visitation, child and
family therapy, substance-abuse treatment, and early education services.
Selected court judges have received special training in early childhood
development and handling cases with children under age 3 years. With an
annual budget of approximately $2 million, the C2C Judges were able to
dismiss dependency cases on 399 children in FY 2014, with an average case
age for dismissed children during this time period being 533 days. These data
are significantly better than the overall population of the Juvenile Court Bench,
which dismissed dependencies in 282 children during that same time period
with an average case age of 907 days.
MCSTART is a children’s behavioral health clinic housed in Door to Hope, a
501 (C)(3) that initiated children’s services in 2003. Medicaid (EPSDT), child
welfare (Title IVE), substance abuse block grant monies, and private
9 | P a g e
foundation funding support MCSTART’s public/private partnership budget of
$2.9 million. Clinical staff members, consisting of a physician, physicians’
assistant, child psychologist, 5 doctorate level therapists, an occupational
therapist, 6 parent educators, 4 case managers, and 15-20 mentor parents,
serve 400-450 children per year through a transdisciplinary approach.
Desert Mountain Children’s Center (DMCC) is a clinical services program
housed within San Bernardino County’s Department of Education and is
governed by the school district’s 15 school superintendents. Medicaid
(EPSDT), department of education, department of health (Title V) and private
foundation funding support the program’s annual budget of $2.5 million. Public
health nurses conduct outreach and screening throughout the community, and
children move through a series of increasingly complex levels of service.
DMCC providers conduct complex assessments that include evaluation of
medical, developmental, psych/social, occupational therapy and speech and
language status. Based on the assessment, recommendations are made to the
parent/guardian of the child and appropriate referrals are instituted. On site at
DMCC, a variety of treatment services are available: Individual/Family
Psychological Therapy, Parent/Child Interaction Therapy (PCIT), Theraplay®,
Play Therapy, Occupational Therapy / Sensory Processing, and Speech and
Language Therapy.
From a funding perspective across the three programs, costs/child for services
covered a wide range: $2500 to $5450. However, Medicaid EPSDT (Early
Periodic Screening, Diagnosis and Treatment) funding covered a significant
amount of this cost and can be a core source of funding for sustainable clinical
services. In addition, Title IV-E funding through the child welfare system can
be a source of funding for training of professionals and training and supporting
foster, adoptive and biologic parents. Title V federal funding through the
state’s Maternal and Child Health office provides enhanced outreach and
support services for Medicaid eligible pregnant and parenting women.
Prenatal Risk Data
Dr. Ira Chasnoff and NTI Upstream have been working in Hawai‘i to address
substance use in pregnancy since April 2007. At that time, a team of community
leaders invited Dr. Chasnoff and his team to guide the development of a
comprehensive model of prevention and intervention for families on Hawai‘i
Island. The team membership brought together representatives from various
agencies and community health centers, as well as community-based
professionals in pediatrics, early childhood education, hospital administration,
mental health, schools, substance abuse treatment, tobacco cessation, and
child protection.
As a result of that planning effort, pregnant women enrolled in prenatal care
throughout Hawai‘i Island for the past eight years have been screened with the
4P’s Plus, a validated, published screening instrument that identifies pregnant
women at risk for alcohol, tobacco, and illicit drug use. In 2012, through funding
10 | P a g e
from the Hawai‘i Community Foundation, the screening program was
expanded to include sites on Oahu, and in 2014, outreach added Maui and
Moloka‘i. Those women with a positive screen undergo a more thorough
structured clinical intervention conducted at the same prenatal visit and
receive a brief intervention to educate them about substance use and then, as
appropriate, a referral to treatment. Widely published data have demonstrated
the success of this approach, and the federal government’s National Prevention
Task Force recommends that this strategy be utilized for all individuals enrolled
in prenatal care.
On Hawai‘i Island and Oahu, as of May of this year, 6,879 pregnant women have
been screened. The majority of the women screened are in the 19 to 34 years
age range, with 18% adolescents, and 9% of the women 35 years and older. In
response to the 4P’s Plus© screening questions, 26% of all women in the
participating sites admitted to tobacco use, 30% admitted to alcohol use, and
9% admitted to illicit drug use. Native Hawai‘ian women and Caucasian women
have the highest rates of using alcohol, and Native Hawai‘ian women have the
highest rates of tobacco use. For the entire population of women enrolled in
the study, 35% were using a substance that affects the structure and function of
the developing fetal brain.
Children’s Behavioral Health Risk
In response to multiple requests for help from Hawai‘i’s families, Dr. Chasnoff
and his team operated a free clinic on Hawai‘i Island. The purpose of this clinic
not only was to provide direct assessment and treatment services to children in
Hawai‘i, but also to try to get a first picture of the behavioral health difficulties
among children in the islands. The clinic was held on Hawai‘i Island, one week
at a time, three times per year for three years. Dr. Chasnoff brought a nurse and
a clinical psychologist from the mainland with him on a volunteer basis. Local
pediatricians provided space for the clinic in their offices at no cost. Histories
were collected on all cases referred to the clinic, and the children were
selected for assessment based on their acute need and the likelihood that the
assessment could provide them with a treatment plan that would improve their
current status.
Over 100 children were referred to Dr. Chasnoff by Hawai‘i pediatricians,
courts, and child welfare in 2011-2013. Of these children, 65 were selected to
undergo a comprehensive assessment. The children primarily came from
Oahu, Maui, and Big Island. A random sample of 22 children ranged in age
from 4 months to 16 years. Behavioral problems were the primary reason for
referral. Of the 22 children, 10 met criteria for a diagnosis within Fetal Alcohol
Spectrum Disorders, 6 had significant intellectual disabilities, 4 were
diagnosed with attention deficit hyperactivity disorder (ADHD), and 13 had a
significant mental health disorder.
None of the 22 children had ever had a full evaluation. When comparing the
multiple diagnoses that had previously been given to the children to the
diagnoses that resulted from the comprehensive assessment, 18 (82%) had
11 | P a g e
been misdiagnosed. This high rate of misdiagnosis is consistent with the 85%
rate of misdiagnosis documented in a recent study of children in Illinois
published by Dr. Chasnoff and his colleagues in February 2015 in Pediatrics.
In examining the children’s histories, several common reasons for the high rate
of misdiagnosis emerged:
• Failure to identify risk factors, such as alcohol and drug use, in the
prenatal period. Pediatricians especially are unaware of the mother’s
use of alcohol, tobacco or illicit drugs during the pregnancy.
• Lack of children’s primary care providers’ ability to recognize risk and
know what to do for a child at risk for behavioral and mental health
disorders.
• High rate of co-occurring mental health disorders.
• Lack of assessment across all domains of child functioning.
• Limited treatment resources forced inappropriate use of medications to
address any behavioral or mental health problems.
• Multiple moves within the child welfare system resulting in constantly
changing educational placements and health care providers.
• Perceived stigma against mental health and substance abuse disorders
in families.
Survey of Hawai‘i’s Clinical Programs for Children
A survey was designed to examine the degree to which programs in Hawai‘i
are implementing the components of a SMART system of care. The survey was
distributed in January 2015 to 86 agencies across the state. Research of
websites associated with Aloha United Way Search 211; Hawai‘i Department of
Human Services and Department of Health; Children, Adult, Mental Health
Division (CAMHD) grantees; Early Intervention providers; and Home Visiting
contractors provided the list of potential participants. In addition, each of the
six Head Start/Early Head Start grantees and the 14 FQHC providers were sent
a survey. Programs were emailed a weblink that would connect the programs
to the on-line survey. Confidentiality of specific programs was ensured.
After the initial response, follow up phone calls and emails were sent to
programs to answer any questions and remind them to complete the survey.
For several programs, the data were collected during a phone conversation
and manual entries were made.
Sample Forty-six surveys were completed. Nine of the programs
responded that they served children over the age of 8 and were therefore
excluded from the sample. The remaining 37 respondents were sorted; seven
more were excluded from further analysis: 3 because they do not provide
direct services but serve as advocacy agencies and four because they had
incomplete surveys. The final sample that was analyzed was comprised of 30
agencies.
12 | P a g e
These 30 agencies represent a wide range of programs that varied in the
number of children age birth to eight served annually [10 to 5000], the number
of sites at which services were offered [1 site to 38 locations], and the overall
size of the agency. The respondents ranged from statewide, very large multi-
service agencies that served a large number of zip codes to smaller therapeutic
settings that served one zip code. Collectively, the 30 agencies serve over
25,000 children (birth-8) annually.
Methodology and data analysis All of the programs’ responses were scored
based on the degree to which they implemented SMART components. There is
no viable methodology for measuring “decision making” through a survey
approach, so only the action components (screening, assessment, referral,
treatment) were included in the programs’ evaluation. Each of the four action
steps was given one of three scores: a blank rating [they did not provide this
service]; a lower case letter: they provided this service but not to the degree
necessary for a high-quality SMART system; or an upper case letter: they
provided the component necessary for SMART quality (Table 1). Dr.
Weisenfeld assigned these codes to each program in the sample based on the
self-reported data submitted by the survey responder.
Table 1. Scoring System for Clinical Program Survey
Did not
provide this
component
Provides this component
but not to the degree
necessary for SMART
quality
Provides this component
necessary for SMART
quality
Screening No rating Rating: s
Screens children, but
did not use a valid or
reliable tool
Rating: S
Screens children using a
valid and reliable tool.
Assessment No rating Rating: a
Assesses children but
does not include a
clinical interview,
and/or instruments,
and/or multi-
disciplinary team.
Rating: A
Assesses children using a
clinical interview, and/or
instruments, and/or
multi-disciplinary team.
Referral No rating Rating: r
Makes referrals to
programs, but does not
have a system in place
to track child’s entry into
the program.
Rating: R
Makes referrals and has a
procedure for tracking
child’s entry into the
program.
Treatment No rating Rating: t
Provides treatment but
does not use published
evidenced-based
therapies.
Rating: T
Provides treatment using
published evidenced-
based therapies.
13 | P a g e
After the programs were assigned a code, the surveys and results were
reviewed and verified by Dr. Chasnoff. Any disagreement between the two
coders was resolved through consensus.
Results The following table summarizes the data obtained through the
survey for the 30 programs.
Do not provide
this component
Provides this
component but
not to the degree
necessary for
SMART quality
Provides this
component
necessary for
SMART quality
Screening 8 7 15
Assessment 12 14 4
Referral 8 13 9
Treatment 10 13 7
Screening 22 programs responded that they screen children. The
most common tools used were Ages & Stages-III (ASQ) and Ages and Stages-
Social Emotional (ASQ-SE). However, not all children within the programs
are screened; rather, the programs select which children will be screened,
often after a clinical assessment. Formal screening instruments were more
likely to be implemented in center-based programs, such as Head Start and
family child interaction programs (FCIL)12 programs, whereas in federally
qualified Community Health Centers, a clinical interview approach more
typically is used to screen the children. Statewide, the estimated number of
children screened is about 30%.
It should be noted that in the past five years numerous statewide workgroups
have been organized to address children’s developmental screening:
• Action Strategy: Team 3 (Governor’s Office)
• American Academy of Pediatrics: Building Bridges
• Child Mental Health Initiative (DOH)
• Early Childhood Comprehensive Systems: Screening Management
Team (DOH)
• EPSDT Workgroup (DHS)
• Hawai‘i Child Welfare Services-Program Improvement Plan (PIP2)
Steering Committee (DHS)
• Hawai‘i Wrap Services Project Coordinating Committee (DHS)
• Healthy Child Care Hawai‘i (DOH, UH)
• Hui Kupa`a Collective Impact (Governor’s Office & Phocused)
• Maternal Child Health Workforce Development (DOH)
• Screening and Assessment Workgroup (CWSB, DHS)
• Title V Screening Work Group (DOH)
14 | P a g e
Most of these workgroups identified valid screening tools to be used for
screening; however, different tools were selected by different workgroups. For
those recommending the same instrument, there is not a consistent cut-off score
used to determine when children need services, nor are there common
protocols or policies for screening and referring children who are positive. In
addition, children often are screened multiple times. For example, when
children leave IDEA Part C [Early Intervention, DOH] and enter IDEA Part B
[SPED, DOE] they are re-screened. When children are screened in Head Start,
they are re-screened by the pediatrician, sometimes using the same tool. This
results in a significant amount of money and energy being used up by
screening efforts, depleting resources for needed assessments and treatment.
The lack of a unified data system or even simple protocols for communication
across departments and systems leads to this inefficiency and ineffectiveness.
Assessment There is no central definition of what an assessment means.
Therefore, many groups state they are assessing children, but they are actually
using screening instruments. What assessments occur tend to be focused on
the particular expertise of the provider.
Referral Referrals from one agency to another appear to be
occurring; however, there is no system to track children to ensure that they
follow through on the referral and subsequently receive the appropriate and
defined treatment identified in their assessment plan. As one provider stated
in the survey, “Our challenge is that we have no tracking, nor metrics to
provide details on this population.”
Treatment Most programs that provide treatment are not using
evidence-based models. A limited number of providers are using evidence
based treatment approaches, but in many cases they are using them with
populations for which the program was never intended. Less than 25% of the
programs we surveyed offered high-quality treatment, and these programs
only serve 739 children collectively.
Survey of State Departments and Agencies
In order to better understand the clinical landscape in Hawai‘i, each member
of the Leadership Group was asked to identify all the “narrow gates” through
which children ages 0-5 pass within their department/agency. In addition to
identifying the narrow gates, a template was provided to collect specific
information about what if any child screening occurs at this narrow gate. If
developmental screening does occur, addition information was requested:
Professional background, discipline of personnel conducting the
screening
Number of children screened per year
Instruments or approaches used for screening
Other organizations that might assist in the screenings
Geographic location of screenings
Training and professional developmental opportunities for screeners
15 | P a g e
Quality assurance methods
Monitoring of contractors
Follow up, including brief interventions, provided to children who
screen positive
Tracking system for screening and referral data
Ten “narrow gates” were identified across the agencies and departments;
however one of the gates was a system effort that does not directly serve
children(*):
Child Welfare Services [Department of Human Services]
Med-Quest (Medicaid) [Department of Human Services]
Family Court, 1st Circuit [State Judiciary]
Special Education Section [Department of Education]
Executive Office on Early Learning [Department of Education]
Early Intervention [Department of Health]
Early Childhood Comprehensive Systems [Department of Health]*
Home Visiting Unit [Department of Health]
Child, Adolescent, Mental Health Division [Department of Health]
West Hawai‘i Community Health Center [Federally Qualified Health
Center]
Analysis of the data collected through the survey indicated that among the
responding agencies administered by Leadership Group participants,
approximately 90,000 children birth to age five living in Hawai‘i pass through a
“narrow gate” and have an opportunity for screening. The “narrow gate”
through which the largest percentage of children pass is Med-Quest
(Medicaid). Other gates see much fewer children:
Division/Program/Office Number of Children (0-
5) who Enter this
Narrow Gate Annually
% of Children (0-5) in
Hawai‘i
who Enter this Narrow Gate
Child Welfare Services 1068 (FY 2014) 1.2%
Med-Quest (Medicaid) 50,700 56.3%
Family Court, 1st Circuit 20-30 .02%
Special Education Section 11 .01%
Executive Office on Early
Learning
420 .47%
Early Intervention 3324 3.7%
Home Visiting Unit 603 .67%
Child, Adolescent, Mental Health
Division
65 .07%
West Hawai‘i Community Health
Center
Not available Not available
Some of the Divisions/Programs/Offices assess or evaluate children, but in
terms of screening children for behavioral health, only five
Divisions/Programs/Offices screen children, and these are conducted either
16 | P a g e
by contractors or by staff [as noted]:
Division/Program/Office Group
Conducting
Screening
Number of Children
[0-5] Screened
Annually at this
Narrow gate
% of Children
(0-5) in Hawai‘i
who are
Screened at
this Narrow
Gate
Child Welfare Services Contractors Not available Not available
Family Court, 1st Circuit Staff 20-30 .02%
Home Visiting Unit Contractors Only parents are
screened for risk
factors
---
Med-Quest (Medicaid) Contractors 41,700 46.3%
West Hawai‘i Community
Health Center
Staff 26 .03%
Analysis of the survey data revealed that there are a number of opportunities
for identifying behavioral health risk in children across multiple agencies and
departments. Child welfare services (CWS) has access to all children entering
the system as well as children who remain in the custody of their families but
under CWS supervision. The system relies heavily on primary care providers
to conduct screening and referral, but there is no tracking system that ensures
that this is happening.
The courts have protocols for screening all children, but this “rarely” occurs.
Although capable of screening, it appears that the federally qualified
Community Health Centers screen very few children, and CAMHD and Head
Start, with access to numerous children, do not conduct screenings. It also is
obvious that the public is not aware of access to screening. For example, the
Department of Education’s “Operation Search” had only 11 families call in to
request screening for their children ages 3 to 5 years in the 2014-2015 school
year.
For the two programs in which staff members conduct screening of children,
there was a range of professional qualifications required. One program [Family
Court] requires a Master’s Degree in Psychology or coursework completed for
a PsyD degree. West Hawai‘i FQHC utilizes front desk staff who had a brief
training in administering the questionnaires. For the programs that use
contractors, Med-Quest and CWS rely on medical professionals [i.e.,
physicians, APRNs, and PAs]. Follow up protocols and procedures for those
children who screen positive are unclear and appear to be fairly inconsistent.
The survey also demonstrated opportunities for developing protocols across
systems. Multiple different screening instruments are used across the various
departments and programs, including some that actually are designed for
assessment rather than screening. The mix of screening instruments allows for
identification of different markers across the population and makes it difficult
17 | P a g e
to develop any cohesive idea of what behavioral health difficulties children in
Hawai‘i are facing.
Training on screening is sorely needed. This training should include how to
provide guidance on decision-making as to the next best step for the child and
how to provide earliest intervention within the primary screening site. The
training programs should be followed up with quality assurance activities.
There is very little active review in any programs to assess the consistency and
quality of screening activities.
The survey regarding screening also revealed that there are strong early
intervention services available in the state, primarily through the Department
of Health’s Early Intervention programs for children birth to 3 years and the
Department of Education’s prekindergarten special education services for
children 3 to 5 years.
No matter what narrow gate they may enter, tracking behavioral health data for
children is problematic. Programs are not aware if any prior screening
occurred. Some programs, however, did have information systems that allowed
them to track children internally within their department/program/division,
such as Early Intervention, Home Visiting, DOE’s eCSSS system, CAMHD’s EHR
system, and West Hawai‘i FQHC’s excel worksheet database. None of these
tracking systems communicate with any other.
SMART System of Care Utilizing the data and information gathered through the planning process, the
Leadership Team came to consensus around developing a SMART System of
Care for children birth to 5 years throughout the state of Hawai‘i. As
described previously in this document, the SMART System of Care is a coordinated and integrated system of health and behavioral health care for
all children. It is grounded in13: • Screening
• decision Making
• Assessment
• Referral
• Treatment
Planning is dedicated to a shared vision for the children’s behavioral health
system of care:
Hawai'i's children will be born healthy and will thrive physically,
socially, and emotionally, supported by safe, nurturing families and
an integrated system of universal behavioral health screening,
assessment, referral and treatment that will promote the ultimate
well-being of all children and their success in school.
The central aim of the of SMART System of Care is to identify all children who
are at risk for medical, mental health, emotional, developmental or learning
18 | P a g e
problems and ensure they and their families receive the appropriate level of
assessment and treatment they need for the children to succeed in school and
in life. The overall structure of the system can be defined through a four-tiered
pyramid based on a response to intervention model:
Tier 1 – All children receive Tier 1 interventions through
universal screening of pregnant women and screening of all children. This
tier is grounded in universal public and professional education that
addresses children’s behavioral health, including reducing the stigma
associated with mental health difficulties. Classroom teachers, health care
providers, and others who interact with children and families provide
earliest interventions and supports.
Tier 2 – Based on universal developmental and behavioral health
screening, children identified as “at risk” via a positive screen and for
whom Tier 1 interventions are not supportive enough receive Tier II early
intervention. These interventions, including family support and guidance,
can occur in the medical offices, the classroom, or through IDEA services
(Part C for children 0-3 years, Part B for children 3-5 years).
Tier 3 – Children who are not making adequate progress through
Tier 2 interventions or children whose family environment cannot support
positive behavioral and mental health development will move into Tier 3
interventions. Tier 3 interventions are grounded in targeted assessments
and address areas of deficit through group interventions, parenting
education and support, and school-based intensive instruction, specific to
the child’s area(s) of need. Specialized clinical programs in the
community, specialists in the specific area of deficit or risk, and the
schools provide Tier 3 interventions.
Tier 4 – Children who are not making adequate progress through
Tier 3 interventions or children with complex needs, including those
whose family environment does not function in a way to promote healthy
development, will receive Tier 4 interventions. Tier 4 interventions are
grounded in a comprehensive assessment across all domains of child and
family functioning that results in a wide-ranging and comprehensive
Tier 4
2-4% of children
Tier 3
6-8% of children
Tier 2
10% of children
Tier 1
80% of children
19 | P a g e
treatment plan that can guide interventions across multiple domains. The
comprehensive assessments are conducted and the treatment plans are
developed within a highly trained, multidisciplinary children’s
neurodevelopmental health center. Therapy is provided through this
center or through community-based providers with special, high quality
expertise.
The following descriptions provide more detailed information for each tier
and how children will move through the system of care.
Tier 1
Description
All children receive Tier 1 interventions through universal screening of
pregnant women and screening of all children birth to 5 years. This tier is
grounded in universal public and professional education that addresses
children’s behavioral health, including reducing the stigma associated with
mental health difficulties. Classroom teachers, health care providers, and
others who interact with children and families provide interventions and
supports.
Goal 1A for Tier 1: Professionals and the general public will understand the
importance and impact of behavioral health problems in children. Outcomes:
1. Through a public health campaign, 75% of the general public will be
able to communicate the importance and impact of behavioral health
problems in children.
2. Through professional education, 75% of clinicians across a broad
spectrum of disciplines will:
a. Demonstrate a statistically significant increase in knowledge
regarding the prevention of and interventions for children’s
behavioral health problems.
b. Be able to communicate the importance and impact of
behavioral health problems in children.
Goal 1B for Tier 1: Women’s prenatal care providers and clinic personnel will
effectively screen and identify all pregnant women at risk for alcohol,
tobacco, and illicit drug use. Outcomes:
1. 75% of women’s and children’s health care providers and clinic
personnel in each of the islands will participate in the training and
technical assistance activities of this initiative.
2. At the completion of training activities, 75% of participants will
demonstrate a statistically significant increase in knowledge regarding
alcohol, tobacco, and illicit drug use in pregnancy and its impact on the
child.
Goal 1C for Tier 1: Pregnant women using alcohol, tobacco, and illicit drugs
20 | P a g e
will be identified in the prenatal care setting and receive an appropriate level
of intervention. Measurable objectives:
1. 90% of women enrolled in prenatal health care will be screened for
alcohol, tobacco and illicit drug use.
2. 90% of women who have a positive screen for alcohol, tobacco, and
illicit drug use will receive a brief intervention in the prenatal health
care setting.
3. 90% of pregnant women who require further evaluation and
treatment will receive a referral to an appropriate treatment
program.
Goal ID for Tier 1: Children at risk for behavioral health problems will be
identified in a variety of clinical, social service, and educational settings and
receive an appropriate level of intervention. Outcomes:
1. 90% of children enrolled in children’s health care, social service and
educational services will be screened for risk of behavioral health
problems.
2. 90% of children who have a positive screen for risk of behavioral health
problems will receive site-based early intervention services.
3. 90% of children identified through early intervention services but who
need further evaluation and intervention will be referred to Tier 2
services.
Funding Sources to Achieve this Goal
Currently used sources of funding to cover these costs, including screening,
workforce development, parent education, and advocacy:
Head Start [Federal funds distributed to non-profits in the state] (FY2015
federal grant to non-profits is $20,035,000, this includes all HS services,
not just screenings)
Title V [Child Health] (Block grant for FY2015 is $2,144,047, this includes
all activities)
Maternal Infant Early Childhood Home Visiting [MIECHV/ACA] (FY2015
$1,000,000 and an additional $8,430,783 of discretionary funds; there is
also a state match)
Early Childhood Comprehensive Systems Grant [Federal grant through
the Health Resources Services Administration (HRSA)] ($140,000)
Title IV-B [Child Welfare Service Branch, DHS] (FY2015 is $2,032,258,
this includes all CWSB activities)
Aloha United Way’s Developmental Screening Programs (FY2015
$105,181)
Project LAUNCH [short term SAMHSA grant]
Currently unused, or slightly used, but potential sources of funding to cover
these costs, including screening, workforce development, parent education,
and advocacy:
21 | P a g e
Title XIX, EPSDT ($119,757,247; there is an additional state match)
Private Insurance payers
Child Care Development Fund [CCDF] ($4,971,630, primarily pays for
child care)
Preschool Development Grant ($14,000,000 2015-2018)
Early Head Start/Child Care Grant (FY2016 $1,400,000)
Screening for and treating maternal depression through Title V Maternal
Child Health Block Grant (MCHBG)
Activities that Contribute to this Goal
Public health campaign addressing children’s behavioral health risk
and interventions
Professional education addressing children’s behavioral health risk
and interventions
Screening pregnant women for substance/toxic exposure
Providing a brief intervention to pregnant women
Conducting behavioral health screenings on children birth to 5 years
Storing child-level data on screenings
Sharing data from screenings with referral resources
Training those conducting screenings
Convening workgroups to discuss screening policy
Educating families on conducting screenings
Hawai‘i’s Progress on Meeting Goal
Screening, brief intervention and treatment for pregnant women using
alcohol, tobacco and illicit drugs
The majority of federally funded Community Health Centers, some
private practices, and a variety of public health and social service
agencies are screening pregnant women for alcohol, tobacco and illicit
drugs, providing a brief intervention on-site, and referring to treatment
as needed. Current data regarding substance use among the
approximately 7,000 women who have been screened were presented
previously in this document.
Conducting developmental screenings on children [before age 5]
Statewide, the current estimated number of children screened is about
30%.
Screening typically is conducted by:
Primary Care Providers: pediatricians, pediatric specialists, family
physicians, community health centers, general practice, internal
medicine
Head Starts/Preschools/Child Care Providers/Home Visitors
The tools commonly used [and the groups using them] are:
22 | P a g e
Ages & Stages Questionnaire; Ages & Stages Questionnaire: Social
Emotional [ASQ, ASQ-SE]: Home Visitors [DOH and DHS], Child
Care/Preschool providers, Head Start
Parents’ Evaluation of Developmental Status [PEDS]: Hawai‘i
Pediatricians
Rapid Assessment Instrument (RAI) for children 4-18 [CWSB, DHS]
Child Behavioral Checklist (CBCL) for children 2-3 [CWSB, DHS]
In SFY2012, 72.2% of children eligible for EPSDT screenings were
screened.
DHS administrative rules for child care (family child care and center-
based) have an Integration of Mental Health Concepts item, which
requires that the provider regularly communicate with the
parents/guardians about the child's development and that the provider
be aware of community resources to help recognize and foster age
appropriate behavioral development in children and share the
information of community resources with the parents/guardians.
However, there is not a requirement that the provider conducts
developmental screenings.
Storing child-level data on screenings
There have been some attempts to store child-level data, but only in
certain communities, both of which are located on Oahu.
Training those conducting screenings
Numerous training opportunities occur that at times cover
developmental screenings, including using ASQ and ASQ-SE. Some
examples of these include:
Family Child Interaction Learning (FCIL) programs conduct own staff
trainings or contact DOH for support
Family, Friend, and Neighbor (FFN) training through Learning to Grow
(DHS, CCDF Quality dollars) funding
Hawai‘i Association for the Education of Young Children (HAEYC)’s
annual conference
Hawai‘i Home Visiting Network
Head Start annual training
The Parent Line (this contract requires contractors to provide training of
trainers on ASQ)
Convening workgroups to discuss screening policy
The following groups have been meeting in the past five years to discuss
developmental screening policy:
• Action Strategy: Team 3 (Governor’s Office)
• American Academy of Pediatrics: Building Bridges
• Child Mental Health Initiative (DOH)
23 | P a g e
• Early Childhood Comprehensive Systems: Screening Management
Team (DOH)
• Hawai‘i Child Welfare Services-Program Improvement Plan (PIP2)
Steering Committee (DHS)
• Hawai‘i Wrap Services Project Coordinating Committee (DHS)
• Healthy Child Care Hawai‘i (DOH, UH)
• Hui Kupa`a Collective Impact (Governor’s Office)
• Maternal Child Health Workforce Development (DOH)
• Screening and Assessment Workgroup (CWSB, DHS)
• Title V Screening Work Group (DOH)
Next Steps
1. Increase the number of children screened:
Support pediatricians by helping problem solve some of the common
barriers they identify: a lack of time to administer screens during health
visits; inadequate compensation; lack of training in the use of specific
tools; and lack of, or perceived lack of, assessment and treatment
resources14.
Help EPSDT and private insurance plans in using the existing procedure
code (CPT code 96110) for enhanced reimbursement to providers for
using a validated tool to perform developmental screening.
Review the Medicaid state plan in terms of allowable locations for
screenings, the qualifications of who can bill for screening children, what
specific services are individually reimbursed by Medicaid, allowable
frequency of screening reimbursement, and the amount paid for each
service.
2. Align developmental screening policies:
Determine the state agency or entity that will be the decision maker for
policy decisions. One department could then order and sell the kits and
offers trainings to providers [currently this is being done by DOH for the
newborn metabolic screenings with the hospitals]
Coordinate and possibly combine some of the workgroups that have
been discussing developmental screening.
Collectively identify the valid screening tools that will be used
statewide.
For those using the same tools, identify a consistent cut-off score used to
determine when children need services.
Include all funding experts (EPSDT or private insurance payers) in the
workgroups
Develop common protocols or policies for screening and administering
the tool and referring children who are positive
Incorporate developmental monitoring into DHS child care licensing
requirements.
24 | P a g e
3. Support workforce development:
Advocate for the regular use of developmental screening tools in the
care of pediatric patients be incorporated into training programs for
medical residents, pediatric nurse practitioners, MORE
Developing a statewide training plan for selected tool[s], possibly
working with CCDF training funds [DHS], supporting providers in
conducting workshops on talking to families about it, and understanding
what to do with results
Working with ASQ/Brookes and other publishers if identified to see if
there is a way to develop a certification/license [like first aid]
Tier 2
Description
Based on universal developmental and behavioral health screening, children
identified as “at risk” via a positive screen and for whom Tier 1 interventions
are not supportive enough receive Tier II early intervention. These
interventions, including family support and guidance, can occur in the medical
offices, the classroom, or through IDEA services (Part C for children 0-3 years,
Part B for children 3-5 years).
Goal for Tier 2: All children who need early intervention services will have
access to appropriate services through a variety of public and private agencies. Outcomes:
1. 90% of children identified as requiring Tier 2 assessment will receive an
appropriate assessment.
2. 90% of children whose assessment indicates a need for early
intervention services will receive appropriate services.
3. 90% of children who do not demonstrate progress in Tier 2 services will
be referred to Tier 3 services.
Funding Sources to Achieve this Goal
The primary source of funds currently being used to pay for the services within
this tier come from the US Department of Education’s Individuals with
Disabilities Education Act [IDEA]. Early Intervention (EI), Part C covers
children up to the age of 3 ($2,148,926 FY15) and Special Education Preschool,
Part B children aged 3 to 5 ($903,031; state match $257,701).
There is not a sliding scale in the state regulations for the EI program. There is
a clause in the statute that says that if children are eligible for Part C, the private
insurance companies do not have to pay for these services.
Activities that Contribute to this Goal
Appropriate and accurate interpretation of screening information
Referring children to early intervention with relevant data
Informing families/community about EI/SPED services
Training EI/SPED staff
Providing direct EI/SPED services to children
25 | P a g e
Receiving, storing, and sharing data on services provided with other
providers
Hawai‘i’s Progress on Meeting Goal
Appropriate and accurate interpretation of screening information
The degree to which this is occurring cannot be determined.
Referring children to early intervention with relevant data
Early Intervention referrals primarily come from physicians.
The intake data system at DOH is being updated; currently it does not
ask if Home Visitors refer children, even though they have been. So
there may be more pathways that are being utilized to refer children,
however there is not any data to verify this.
Each agency has a different cut-off for making referrals [even if though
they mainly use the ASQ-SE].
Informing families/community about EI/SPED services
Hawai‘i’s Department of Health operates Hawai‘i Keiki Information
Service System [H-KISS] for up to age 3 and The Parent Line for children 0-
20.
Hawai‘i Department of Education’s Operation Search [ages 3-20].15
The Hilopa‘a Family to Family Health Information Center provides free
information and assistance to families and professionals on referrals,
technical assistance and training.16
The Parent Line
Training EI/SPED staff
In a recent State Systemic Improvement Plan (SSIP) Provider Survey17:
One in four staff report that they are not comfortable in understanding
age-appropriate social-emotional skills for children [birth to age 6]
63% report waning more training on communicating about sensitive
issues to the cultural stigma related to mental health services
Respondents wanted training on challenging behaviors [73%], social-
emotional development [57%], evidenced based practices in social-
emotional development [72%]
In Hawai‘i, there is a need for more speech, language, and physical therapists.
One of the barriers that has been identified by DOH is the procedure that DHRD
implements takes a long time approving positions, so there is a delay in hiring
people.
Providing high quality, direct EI/SPED services to children
Quality of Services
Early Intervention
26 | P a g e
Hawai‘i has a lower percentage of children with a substantial increased rate of
growth compared to the nation in social-emotional development and
knowledge and skills.18
About 3 in 10 children with military insurance and about 2 in 10 children with
Medicaid [QUEST] did not achieve age-level functioning, compared to about 1
in 10 children with private insurance. 19
Almost 9 in 10 children eligible for EI services due to biological risk maintained
or achieved age-level functioning. More children will developmental delays did not age-level functioning (22%). Almost 4 out of 10 children eligible due
to biological risk and developmental delay were not functioning on par with
their peers at exit from EI. 20
Special Education Preschool
Of those children who entered the program below age expectations in each of
the following outcome, the percent who substantially increased their rate of
growth by the time they turned six years of age or exited the program in the
outcome of21:
Positive social-emotional skills (96.5%)
Acquisition and use of knowledge and skills (97.6%)
Use of appropriate behaviors to meet their needs (95.1)
The percent of children who were functioning within age expectations in each
of the following outcomes by the time they turned six years of age or exited the
program:
Positive social-emotional skills (51.2%)
Acquisition and use of knowledge and skills (51.1%)
Use of appropriate behaviors to meet their needs (60.0%)
Service Delivery
Almost 4% of Hawai‘i’s infants and toddlers receive Part C, Early
Intervention services22 and 4.9% receive services under Part B, Special
Education Preschool23.
Early Intervention in Hawai‘i does not implement a medical model. They
are a primary source provider through a coaching model. Typically, the
therapists go into a child’s home for 25-30 hours per week.
Unfortunately, the parent sometimes views this service as “babysitting.”
19% of the children referred for EI are deemed ineligible.
Children who receive EI services do so through private providers who
have state contracts [85%] and through state provided services [15%].24
There is a lack of community sites to support serving children in natural
environments when families do not want providers in their homes.
Transition from Part C to Part B
Part C [operated by DOH] serves children up to age 3, and then they
27 | P a g e
transition to Part B [operated by DOE]. There are several mechanisms
in place to encourage a smooth transition and continuation of services
for children:
An MOA/MOU is in the process of being finalized by the DOH and DOE.
There is a STEPS State team and local STEPS teams, which bring together
Part C and Part B. This worked successfully years ago in aligning
policies, offering joint training, supporting families and children through
transitions of care, but has faced challenges. The challenges identified:
No DOE person who is solely responsible for 619. In the past DOE
had this position, the current person has lots of other responsibilities.
619 Coordinators [Part B, DOE] are not meeting as a team anymore.
No longer are the Part C and Part B attending joint trainings.
DOE does not accept Part C evaluations
Receiving, storing, and sharing data on services provided with other
providers
Early Intervention uses two different data systems one which stores
children’s social-emotional levels [as measured by the BDI-2] and
another that stores the Child Outcomes Summary [COS] rating. Both of
these systems are non-web-based. The COS ratings are entered into the
Hawai‘i Early Intervention Data System (HEIDS) which is intended to
“improve service delivery for children, assist providers in managing
their programs, and provide Hawai‘i Part C administration with data for
the purpose of assessing compliance with federal and state reporting
requirements.” 25
Next steps
1. Increase access to appropriate early intervention services:
Assess availability of programs
Educate front line screeners as to programs available and how to make
referrals
Educate families as to early intervention programs, their purpose, and
their availability
Promote self-referral to early intervention programs.
2. Align early intervention eligibility guidelines and policies:
Determine eligibility criteria and assess gaps in services that may exist
due to these criteria
Educate professionals and families as to the eligibility criteria for various
early intervention programs
28 | P a g e
Expand, when possible, eligibility criteria beyond purely
developmental or educational issues to include the broader range of
behavioral health difficulties faced by young children
Coordinate access efforts with work groups and organizations
addressing universal screening
Ensure payment pathways for early intervention services
Require that all children birth to age 3 entering the foster care system be
assessed thru IDEA Part C Early Intervention program.
3. Support workforce development
Educate early intervention professionals as to broader implications of
behavioral health challenges beyond current organizational definitions
Developing a statewide training plan for families and early intervention
specialists
Tier 3 Description
Children who are not making adequate progress through Tier 2 interventions
or children whose family environment cannot support positive behavioral and
mental health development will receive Tier 3 interventions. Interventions are
grounded in targeted assessments and address areas of deficit through group
interventions, parenting education and support, and school-based intensive
instruction, specific to the child’s area(s) of need. Specialized clinical
programs in the community, specialists in the specific area of deficit or risk,
and the schools provide Tier 3 interventions.
Goal for Tier 3: All children who need focused therapeutic services will have
access to appropriate services through a variety of public and private agencies.
Outcomes:
1. 90% of children identified as requiring Tier 3 assessment will receive
an appropriate assessment.
2. 90% of children whose assessment indicates a need for focused
therapeutic services will receive appropriate services.
1. 90% of children who do not demonstrate progress in Tier 3 services
will be referred to Tier 4 services.
Funding Sources to Achieve this Goal
EPSDT should be the primary source to pay for funding of clinical services for
children within this level. The required state match is 50%.
There are other sources of funding that support some Tier 3 efforts including:
Enhanced Healthy Starts is a Home Visiting program with active Child
Welfare Service Branch [CWSB] paid for by TANF funds [$2,800,000,
annually].
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Title IV-B2 service categories for specific populations, primarily focused
on neighbor islands and in rural communities. [SFY2013 $946,084].
Hawai‘i has chosen for its Title IV-E waiver to address using data to
inform practice and re-entry into foster care.
Currently unused but potential sources of funding to cover these costs, include:
Title IV-E funding can be a source for training of professionals and
training support of foster, adoptive and biologic parents.
Title XIX federal funds provides an opportunity to enhance outreach and
support services for Medicaid eligible pregnant and parenting women.
Local foundations.
Title XIX to pay for public health nurses to provide care coordination.
Finance early childhood mental health consultation with CCDF funds
[thru quality dollars’, by transferring TANF funds to CCDF or the Social
Services Block Grant [SSBG], with Medicaid/EPSDT [for individual
children].
Activities that Contribute to this Goal
Ways that activities/projects/programs support children’s Tier 3 targeted
assessments and interventions before age 5:
Conducting a targeted assessment of child and family functioning that
results in a treatment plan that can guide interventions targeted at the
child’s specific deficits and challenges.
Receiving, storing, and sharing data on services provided with other
providers
A referral system will ensure that all children will have access and be
linked to the appropriate community based services indicated in the
treatment plan
Providing therapy through community-based providers with special,
high quality expertise
Hawai‘i’s Progress on Meeting Goal
Conducting a targeted assessment of child and family functioning that results
in a treatment plan that can guide interventions targeted at the child’s specific
deficits and challenges.
Statewide, there is no central definition of what an assessment means.
Therefore, many groups state they are assessing children, but these
assessments tend to be focused on the expertise of the providers.
Assessment is limited to the knowledge and capabilities of the
workforce.
The group that appears to be consistently providing targeted
assessment for children is the federally qualified health care centers
[FQHCs]. The FQHCs only serve children who are Medicaid eligible.
There are a few providers that assess children, but their numbers are
quite small [12-75 children] and tend to be focused on specific
populations, such as families experiencing domestic violence and/or
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homelessness. Some of the programs that conduct assessments
reported having waiting lists for children needing to be assessed.
Receiving, storing, and sharing data on services provided through other
providers.
DHS has continued to rely on and make minor changes to its automated
computer data system, Child Protective Service System (CPSS). The
system is used for readily identifying the status, demographic
characteristics, location, and placement goals of every child who is in
foster care. In addition, they have continued to use the SHAKA (State of
Hawai‘i Automated Keiki Assistance) system for certain functions, such
as the 48-hour Tracker to monitor timely response to child abuse and
neglect intakes, the National Youth in Transition Database, worker visit
surveys, tracking completion of transition plans for youth who will be
aging out of foster care, applications for higher education allowances
and education and training vouchers, etc. There have been work groups
and agreements to support CPSS and SHAKA in working together to
develop an effective and user-friendly way to track worker visits with
children.
A referral system will ensure that all children will have access and be linked
to the appropriate community based services indicated in the treatment plan.
Referrals are happening, however there is no system to track these
children to ensure that they receive the appropriate and defined
treatment identified in their assessment plan. One provider commented,
“Our challenge is that we have no tracking, nor metrics to provide details
on this population.”
Again, the group that reports that they have a system in place is the
FQHCs.
Several non-profits report that they have internal systems to track if
families follow-up on their treatment plans. These tend to be more
informal and based on the relationship the program staff have with the
families.
Providing therapy through community-based providers with special, high
quality expertise.
Most programs that provide treatment are not using evidence-based
models.
A limited number of providers are using evidence based treatment
approaches, but in many cases they are using them with populations for
which the program was never intended. Less than 25% of the programs
surveyed offered high-quality treatment, and these programs only serve
739 children collectively.
The Child and Adolescent Mental Health Division’s (CAMDH)
population’s age distribution is heavily skewed, with the largest
proportion of youth served being older, average age 14.1 and the
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Developmental Disabilities Division (DDD) only providers services to
adults.
Next Steps
1. Expand payment options
Support adequate provider payment rates through using a rate
methodology that reflects actual market rates to establish service
reimbursement rates.
Provide support so programs can navigate rules so they can access
EPSDT to pay for services.
The EPSDT required match comes from State funds that are typically
allocated to where the services originate [mostly DHS and DOH]. DOE
is a potential source for additional matched funds.
2. Support DHS/DOH in reviewing and possibly expanding their contract
requirements so that:
Contracted providers have financial incentives and/or sanctions based
on quality of care indicators, and specified outcomes at the system,
program, and child and family levels.
There are funds to carry out contract monitoring activities and reporting.
3. Unify referral process/system
Develop web-based centralized referral system
4. Enhance quality of services
Train the workforce to be certified on various interventions/therapies.
This includes ongoing quality assurance evaluations.
Tier 4
Description
Children who are not making adequate progress through Tier 3 interventions
or children with complex needs, including those whose family environment
does not function in a way to promote healthy development, will receive Tier 4
interventions. Tier 4 interventions are grounded in a comprehensive
assessment across all domains of child and family functioning that results in a
wide-ranging and comprehensive treatment plan that can guide interventions
across multiple domains. The comprehensive assessments are conducted and
the treatment plans are developed within a highly trained, multidisciplinary
children’s neurodevelopmental health center. Therapy is provided through
this center or through community-based providers with special, high quality
expertise.
Goal for Tier 4: All children with complex needs who require comprehensive
neurodevelopmental assessment and therapeutic services will have access to
appropriate services through a central children’s behavioral health center. Outcomes:
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1. 90% of children identified as requiring Tier 4 comprehensive
neurodevelopmental assessment will receive an appropriate
assessment.
2. 90% of children whose assessment indicates a need for
comprehensive neurodevelopmental therapeutic services will
receive appropriate services.
Funding Sources to Achieve this Goal
Currently, there is not an agency or organization operating at this Tier. Once
one is identified, the funds needed to operate these services will include:
Some of the organization or agency’s current operating funds for indirect
or overhead costs.
EPSDT funds, which would require the agency or organization has a
system for billing Medicaid.
Private insurance payers, which also requires a system for billing.
Foundation support.
It is critical to remember that this model of care is only sustainable if multiple
sources of revenue are committed to its success. Moreover, the sources of
revenue must make an enduring commitment to avoid instability.
Activities that Contribute to this Goal
Ways that activities/projects/programs support children’s Tier 4
comprehensive neurodevelopmental assessments and interventions
before age 5:
Conducting comprehensive assessments across all domains of child
and family functioning that results in a wide-ranging and comprehensive
treatment plan that can guide interventions across multiple domains.
These assessments include Pediatricians, Public Health Nurses, Infant
Mental Health specialists and other trained professionals for health and
behavioral health problems that will result in a long-term treatment plan.
Receiving, storing, and sharing data on services provided with other
providers
Providing therapy in a centralized location or in collaboration with
community-based providers with special, high quality expertise
Training a multidisciplinary team to implement high-quality behavioral
health services
Hawai‘i’s Progress on Meeting Goal
Conducting comprehensive assessments across all domains of child and
family functioning that results in a wide-ranging and comprehensive treatment
plan that can guide interventions across multiple domains for children who
require this level of care. These assessments include Pediatricians, Public
Health Nurses, Infant Mental Health specialists and other trained professionals
33 | P a g e
for health and behavioral health problems that will result in a long-term
treatment plan.
There is no formal effort to identify and monitor high-risk children across
all aspects of the Hawai‘i Island community.
There is no single site responsible for ensuring comprehensive
assessment for these children, although a thorough assessment must
guide effective treatment planning.
Receiving, storing, and sharing data on services provided with other
providers
This is not happening in a systematic or uniform way.
Providing therapy in a centralized location or in collaboration with community-
based providers with special, high quality expertise
Service delivery, especially treatment, is based on funding streams, so
that children at risk for health and behavioral health problems are
referred to a variety of providers through specific programs that address
a single need.
Although collaborative efforts have been attempted in the past, there is
little communication among caseworkers in the various agencies.
The school system is marginalized in the overall effort to bring mental
health services to young children. This is not seen as a core
responsibility of the schools’ special education programs except in rare
instances.
Children in families that suffer from substance abuse and domestic
violence live on the periphery of social, medical, and educational
settings so that systems of care never reach them until their complete
failure brings them to the attention of the school system, the juvenile
justice system, or child protective services.
Training a multidisciplinary team to implement high-quality behavioral health
services
To achieve this goal, training must address clinical, administrative, and
procedural approaches to comprehensive and integrated assessment
and treatment.
There is no recognized resource in Hawai‘i for providing this advanced
training.
Next Steps
Identify an agency or agencies that will create a children’s behavioral health
center for Hawai‘i. This center will provide a place where all aspects of a
child’s behavioral health, including emotional, developmental, and biological
health, can be assessed by a multi-disciplinary team and then nurtured to
support the child’s ability to function in every day life, his or her concept of self,
and the ability to relate to others.
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The first six months will be dedicated to start up, with a focus on administrative
organization, identifying and moving into the center offices, purchasing of
supplies and equipment, hiring, and finalizing clinical protocols and service
plans. In addition, as part of the start-up, we will develop the system for billing
Medicaid and other third party payers for services, including private
insurance.
The second six months will be a pilot phase in which children and families will
be seen for services at the center. Protocols will be tested to ensure
appropriate application to Hawai‘i’s unique populations are developed, data
management will be tested, and insurance and third party payer billing
procedures will be tested and finalized.
During the first year of operations, training of local professionals will begin.
Over time, local professionals will assume responsibility for the delivery of
assessment and treatment services.
Advancing the Plan: 2016 As we move into the next year, the “next step” specific strategies presented for
each of the four tiers will guide the next phase of work. Overall, the focus will
be on implementing screening and earliest interventions among early adapter
sites, enhancing the quality of services provided by Tier 3 community
programs, development of the Tier 4 Children’s Behavioral Health Center, and
linking the participating systems.
1. There are several groups currently providing some form of screening of
children at the primary contact level. We need to identify specific groups
who will serve as “early adapters” and develop appropriate Memoranda
of Understanding and data sharing agreements with these groups. One
component of the “early adapter” program will be recruiting physicians
and other health care personnel to participate in the program. Training to
upgrade the quality and consistency of screening and earliest intervention
services will be necessary.
2. Training and professional development is an acute need. It has been the
general consensus of the Leadership Team that training needs lie at the
heart of systems improvement. However, discussions of training have
been nebulous and indirect. When one examines the Tier 1 surveys, it can
be seen that quite a bit of “training” already occurs. However, it does not
appear that it always is of the highest quality, and much of it is peer to peer,
which lacks in quality control. In the early part of the year it is
recommended that the HCF team:
determine precise training needs of each department and division,
most likely via survey, interviews;
determine precise training needs of private agencies throughout
the state, especially those agencies that would provide Tier 3
services;
decide what aspects of training should be supported by the
foundation and which aspects should be left to the departments and
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private agencies;
develop a training of trainer strategy for any training we will
conduct/support so as to make the impact of the training
sustainable;
develop a training schedule, including appropriate faculty.
This will position us in the latter half of the year to begin training in an
organized and meaningful way that is linked to roll out of the system.
3. The administrative and clinical development of the Tier 4 Children’s
Behavioral Health Center will necessarily be a long and slow process that
should be initiated in the early part of the year. This should include site
visits to mainland programs that have been developed through the SMART
system strategy. Other members of the leadership team could well benefit
from the exposure, also.
4. Evaluation, both process and outcome, will be the factor that drives
sustainability and ongoing funding of the system. Good evaluators want to
be involved in the early stages of planning so as to understand the
underpinnings of the program and expectations for outcomes. Thus, we
should bring an evaluation team in relatively soon and start laying out how
we want to document and track change, including cost/benefit analyses.
5. A communication strategy needs to be developed in order to stay ahead of
public expectations. This strategy will need to include action steps with
target audience(s), a timeline, and the development of appropriate on-line
and hard copy print materials for distribution. We might consider the
development of a web site dedicated to the SMART system of care, which
could be used to communicate with professionals as well as the public.
1 U.S. Department of Health and Human Services. (1999). Mental health: A
report of the Surgeon General. Rockville, MD: U.S. Department of Health and
Human Services, Substance Abuse and Mental Health Services Administration,
Center for Mental Health Services, National Institutes of Health, National
Institute of Mental Health.
Friedman, R., Katz-Leavy, J., Manderscheid, R., & Sondheimer, D. (1998).
Prevalence of serious emotional disturbance in children and adolescents. An
update. In R. W. Manderscheid & M. J. Sonnenschein (Eds.), Mental health,
United States, 1998 (HHS Publication No. SMA99-3285) (pp. 100-112).
Washington, DC: U.S. Government Printing Office.
Perou, R. (2013, May). Mental health surveillance among children: United
States, 2005-2011. Center for Disease Control and Prevention Morbidity and
Mortality Weekly Report (MMWR).
36 | P a g e
2 Huang, L., Stroul, B., Friedman, R., Mrazek, P., Friesen, B., Pires, S., &
Mayberg, S. (2005). Transforming mental health care for children and their
families. American Psychologist, 60(6), 615-627.
Clark, H. B., Deschenes, N., Sieler, D., Green, M. E., White, G., & Sondheimer,
D. L. (2008). Services for youth in in transition to adulthood systems of care. In
B. A. Stroul & G. M. Blau (Eds.), The systems of care handbook: Transforming
mental health services for children, youth, and families (pp. 517-543). Baltimore,
MD: Paul H. Brookes.
Cocozza, J. J., Skowyra, K. R., Burrell, J. L., Dollard, T. P., & Scales, J. P. (2008)
Services for youth in the juvenile system in systems of care. In B. A. Stroul &
G. M. Blau (Eds.), The systems of care handbook: Transforming mental health
services for children, youth, and families (pp. 573-593). Baltimore, MD: Paul H.
Brookes.
Epstein, M. H., Nelson, J. R., Trout, A. L., & Mooney, P. (2005). Achievement
and emotional disturbance: Academic status and intervention research. In M.
H. Epstein, K. Kutash, & A. J. Duchnowski (Eds.), Outcomes for children and
youth with emotional and behavioral disorders and their families: Programs and
evaluation best practices (2nd ed., pp. 451-477). Austin, TX: PRO-ED.
National alliance on Mental Illness. (2010, July). Facts on children’s mental
health in America. Retrieved on May 31, 2015:
http://www2.nami.org/Template.cfm?Section=federal_and_state_policy_legis
lation&template=/ContentManagement/ContentDisplay.cfm&ContentID=4380
4
Pullmann, M. D., Kerbs, J., Koroloff, N., Veach-White, E., Gaylor, R., & Sieler,
D. (2006). Juvenile offenders with mental health needs: Reducing recidivism
using wraparound. Crime and Delinquency, 52(3), 375-397.
Wagner, M., & Cameto, R. (2004). The characteristics, experiences, and
outcomes of youth with emotional disturbances. NLTS2 Data Brief, 3(2).
Retrieved on May 31, 2015:
http://www.ncset.org/publications/viewdesc.asp?id=1687
3 These cost estimates are based on research that analyzes cost savings when
systems of care are implemented nationally and within sates and
communities. Hawaii-specific data are not available.
4 Stroul, B., Pires, S., Boyce, S., Krivelyova, A., & Walrath, C., (2014). Return on
investment in systems of care for children with behavioral health challenges.
Washington, DC: Georgetown University Center for Child and Human
Development, National Technical Assistance Center for Children’s Mental
Health.
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Their analysis was based on data obtained from: Agency for Healthcare
Research and Quality. (2013). Emergency room services: Mean and median
expenses per person with expense and distribution of expenses by source of
payment: United States, 2009. Medical Expenditure Panel Survey household
component data.
5 Stroul, B., Pires, S., Boyce, S., Krivelyova, A., & Walrath, C., (2014). Return on
investment in systems of care for children with behavioral health challenges.
Washington, DC: Georgetown University Center for Child and Human
Development, National Technical Assistance Center for Children’s Mental
Health.
6 National Center on Addiction and Substance Abuse (CASA) at Columbia
University. (2004). Criminal neglect: Substance abuse, juvenile justice and the
children left behind. New York: Author.
7 Cornman, S. Q. (2013) Revenues and expenditures for public elementary and
secondary education: School year 2010-11 (Fiscal Year 2011) (NCES 2013-342).
Washington, DC: U. S. Department of Education, Institute of Education
Sciences, National Center for Education Statistics.
8 Sum, A., Khatiwada, I., & McLaughlin, J. (2009). The consequences of
dropping out of high school: joblessness and jailing for high school dropouts
and the high cost for taxpayers (Paper 23). Boston, MA: Northeastern
University, Center for Labor Market Studies.
Carnevale, A. P., Rose, S. J., & Cheah, B. (2011). The college payoff: Education,
occupations, lifetime earnings. Washington, DC: Georgetown University,
Center on Education and the Workforce.
9 National Center on Addiction and Substance Abuse (CASA) at Columbia
University. (2004). Criminal neglect: Substance abuse, juvenile justice and the
children left behind. New York: Author.
10 Texas Department of State Health Services. (2011). Coordinated funding for
children with serious emotional disturbance: Current funding, services and
recommendations. Austin, TX: Texas Mental Health Transformation Working
Group, Children and Adolescent Workgroup, Children’s Coordinated
Funding Committee.
11 Gould, M. (2000). Mental health early intervention program for young
children cost of failure study. Denver, CO: Colorado Department of Human
Services.
Heilbrunn, J.Z. (2010). The cost of services revisited: Kid Connects mental health
consultation as a cost savings investment strategy. Denver, CO: Colorado
Department of Human Services.
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12 Family Child Interaction Learning (FCIL) programs delivery model involves
parent/adult family member participation and child learning time. The
programs require that the adults attend the program with the child.
13 McGourty, R. & Chasnoff, I. (2003). Power Beyond Measure. Chicago: NTI
Upstream, 2003.
14 Sices, L., Feudtner, C., McLaughlin, J., Drotar, D., &Williams, M. (2004).
How do primary care physicians manage children with possible
developmental delays? A national survey with an experimental design.
Pediatrics, 113(2):274-82.
15 To view the Operation Search brochure go to:
http://www.hawaiipublicschools.org/DOE%20Forms/Special%20Education/
Operation_Search.pdf
16 For more information about Hilopaa visit:
http://www.hilopaa.org/Pages/default.aspx
17 Hawaii Department of Health (April 1, 2015). Hawaii Part C FFY 2013
SSP/APR indicator 11: State systematic improvement plan (SSIP), phase 1.
Retrieved on 6/22/2015:
http://health.hawaii.gov/eis/files/2013/05/HawaiiPartCSSIP-PhaseI-
April2015.pdf
18 Hawaii Department of Health (June 2014). Part C early intervention, state
systemic improvement plan: Supporting infants and toddlers social emotional
development. Retrieved on 6/22/2015:
http://health.hawaii.gov/eis/files/2013/05/SSIPBrief-June2014.pdf
19 Hawaii Department of Health (April 1, 2015). Hawaii Part C FFY 2013
SSP/APR indicator 11: State systematic improvement plan (SSIP), phase 1.
Retrieved on 6/22/2015:
http://health.hawaii.gov/eis/files/2013/05/HawaiiPartCSSIP-PhaseI-
April2015.pdf
20 Ibid.
21 These are preschool outcomes for FFY 2012. They are a state-selected data
source. Sampling of children for assessment is allowed. Sample must yield
valid and reliable data and must be representative of the population sampled.
Retrieved on 6/22/2015:
http://www2.ed.gov/fund/data/report/idea/partbspap/2014/hi-acc-
statedatadisplay-12-13.pdf
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22 Early Intervention services offered include: Assistive Technology;
Audiology; Care Coordination; Family Support/education; Health; Nursing;
Nutrition; Occupational therapy; Parent-to-parent support; Physical therapy;
Psychological support; Speech and language therapy; Social work
(counseling); Specialized teaching; Transportation; and Vision.
23 For 2012-2013 SY, retrieved on 6/22/2015:
http://www2.ed.gov/fund/data/report/idea/partbspap/2014/hi-acc-
statedatadisplay-12-13.pdf
24 The private service providers include: Easter Seals; IMUA Family Services;
Ikaika Infant Toddler Development; Kau Child Development Program; Kona
Child Development Program; Waianae Child Development Program; and
North Hawaii Child Development Program.
25 Hawaii Department of Health (April 1, 2015). Hawaii Part C FFY 2013
SSP/APR indicator 11: State systematic improvement plan (SSIP), phase 1.
Retrieved on 6/22/2015:
http://health.hawaii.gov/eis/files/2013/05/HawaiiPartCSSIP-PhaseI-
April2015.pdf