What’s on the horizon?Larke Huang

NASMHPD CYF DiscussionJuly 13, 2010

Topics

• Health Reform: Affordable Care Act Provisions– Prevention– Home Visiting– Postpartum Depression– School-based Health Care Grants– Disparities– Depression Centers of Excellence

• Secretary’s Priorities• Office of Adolescent Health• Place-based Initiatives

Projected State Budget Shortfalls

Source: Center on Budget and Policy Priorities - http://www.cbpp.org/files/9-8-08sfp.pdf

Selected Administration Issues

• Prevention and Wellness– Individual, community and policy change– Obesity, tobacco, chronic disease prevention

• Health and the Economy• Collaboration

– Cross government

• Transparency and Openness– Outcomes and access to information

• Technology– Efficiencies and access– Example: Text-messaging Health Information

Affordable Care Act: SelectedBehavioral Health Grant Opportunities

• Prevention• Community Transformation Grants

• Workforce• Behavioral Health Education and Training • Area Education Centers • Personal or Home Care Aides• Community Team to Support Patient Centered Medical Home

• Demonstration Projects• Early Child Home Visitation Programs

– Released June 10, 2010– Found at: https://grants.hrsa.gov/

• National Centers of Excellence for Depression• Co-Locating Primary and Specialty Care in Community-Based

Mental Health Settings

Affordable Care Act: SelectedBehavioral Health Grant Opportunities

• Medicare and Medicaid (CMS)• Health Home Planning Grants• Incentives for Prevention of Chronic Disease in

Medicaid• Medicaid Emergency Psychiatric Demonstration Project • Evaluation of Bundled Payments for the Provision of

Integrated Care in Medicaid• Evaluation of Community-Based Prevention and

Wellness Programs for Medicare Members• School-Based Health Centers

Affordable Care Act Provision on Home Visiting

• Home Visiting Grants to States– Governor’s Office

– Substance abuse, domestic violence, crime, low SES, child maltreatment, etc.

– Needs Assessment

– Proposal for HV: 2011

– 2010: $100M to States

Secretary’s Prevention Priorities

• Prevent and Reduce Tobacco Use– Smoking, second-hand smoke

– Change social norms

– Alcohol, parents talking with children re alcohol use

Secretary’s Prevention Priorities

• Promote Early Childhood Health and Development– Providing high quality early care and education for young

children

– Support coordination of services for young children and their families

– Helping parents support children’s health and development

– Home Visiting

– Maternal Depression and Early Head Start and Head Start

– Family engagement

Secretary’s Prevention Priorities

• Reduce Teen and Unintended Pregnancies– Invest in evidence-based practices

– Target populations at highest risk

– Insure access to clinical services and health information

– Office of Adolescent Health: $114M grant program

Office of Adolescent Health

• Prevention of Teen Pregnancy

• Enrollment of Adolescents in Medicaid

• Implementing the Recommendations of the Institute of Medicine Report: Preventing Mental Emotional and Behavioral Disorders in Young People (2009)

• Youth Engagement

Prevention Intervention Opportunities (IOM Report, 2009)

Selected Federal Interagency Collaborations

• Interagency Work Group on Youth Programs: Created by Executive Order, 12 agencies/departments to develop Federal strategic plan for youth programs– Conference on Innovative Collaborations for Youth: showcased System

of Care work• Early Learning and Development Interdepartmental

Initiative– Creating a quality early childhood systems focus: Dept of Education

and Health and Human Services– Early Learning Challenge Fund– Mental Health Consultation

• Home Visiting Programmatic Issues Work Group• Collaborating Council on Juvenile Justice and Delinquency

Prevention: priorities include mental health/substance use; trauma and violence; diversion and re-entry courts; disproportionate minority contact

Beyond the “One child at a time” Approach

• Need for a public health approach

• Factors contributing to the “public’s health”

• Population approach with promotion and prevention component

• Prevention is NOT a single intervention

• Interventions must be evidence-based

• Integrated prevention is based in both the community and the health system

• Payment reform is critical

Family Data from a SAMHSA Grant Program

“Most children and youth receiving children’s mental health services (85.2 percent) have other family members who suffer from some type of mental illness; approximately 70 percent were reported to have a biological family member with depression and 46.4 percent have a biological family member with another type of mental illness. In addition, 61.6 percent have a biological family member who abused drugs or alcohol.”

• 148.8 million parents in the U.S.

• 17% parents had major or severe depression in lifetime (Nation Co-morbidity Study-Replication, 2002)

• 7% in past year had depression = 7.5M

• 15.6M children (<18yrs old) living with adult with major depression

• Depression disproportionately affects low income women of color

“Depression in Parents, Parenting and Children”

A Two Generation Approach

Barriers• Facilities and providers specialize in either adults or children,

not both• Rarely asked if adult with disorder has children in the home• Child service system not equipped to identify parents with

substance and mental disorders• Financing of delivery system – based on adult acute care or

individual well-child or acute care

• Treatment for adult may be prevention for the child

• SAMHSA’s Project LAUNCH• SAMHSA’s Pregnant-Postpartum Women in Substance Abuse

Treatment

Trauma in Childhood: Underpinning of Later Chronic Diseases

• Emerging evidence of trauma associated with chronic diseases –physical, mental and substance use

• Experiences in childhood have impact throughout life…brain, cognitive and behavioral development early in life are strongly linked to an array of important health outcomes…including cardiovascular disease and stroke, hypertension, diabetes, obesity, smoking, drug use, and depression… (2008 RWJ Report)

• Adverse Childhood Experiences Study: numbers of ACES in childhood directly linked with chronic diseases (Fellitti, et al)

– Example: 0-5 year olds more likely to be present when domestic violence occurs

– Greater number of ACES linked with physical, emotional and substance use disorders in adulthood

• 8.3M or 11.9% of children live with a substance dependent or abusing parent (SAMHSA, NSDUH, 2009)

Fast Facts re Trauma and Behavioral Health

• Homicide and suicide are 2nd and 3rd leading causes of death among 15-34 yr olds; suicide rate highest among AI/AN young males

• More than 60% of youth have been exposed to violence with past year• One of four adolescent girls engaged in violent behavior in past year (NSDUH, 2010)• Youth engaged in violent behavior in past yr 2-3 times more likely to use drugs or

alcohol (NSDUH, 2009)• Cost of intimate partner violence (esp women/girls) estimated at $8.3B in 2003 (CDC,

2006)• 150 estimated deaths/year due to Seclusion and Restraint use• Adverse Childhood Experiences (e.g. physical, sexual abuse, living with mentally ill or

substance using parent, incarcerated parent, etc) associated with higher rates chronic disease (cancer, CVD, MI, suicidality, SA) risk behaviors (smoking, obesity, sexual behavior) and increased mortality (6+ACES 60.6 yrs)

• 1 of 5 returning veterans diagnosed with PTSD; high rates of minorities among returning veterans

• Historical trauma impacts the physical, mental and economic health of Native American and other diverse racial communities

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SAMHSA’s Strategic Initiative: Trauma and Justice

• Establish a comprehensive public health approach to trauma

• Make screening for trauma and early intervention and treatment common practice

• Reduce the impact of trauma and violence on children, youth and families

• Address the needs of pepole with behavioral health disorders and with histories of trauma within the criminal and juvenile justice system

SAMHSA’s Strategic Initiative: Prevention

• Build emotional health; reduce or eliminate substance abuse and mental illness

• Prevent and eliminate underage drinking and adult problem drinking

• Prevent suicides and attempted suicides among populations at high risk, esp military families, youth and tribal members

• Reduce prescription drug misuse and abuse

SAMHSA: Prevention Prepared Communities

• Create a national, evidence-based, and community-oriented prevention system for promoting mental, emotional, and behavioral wellness among young people

• To improve Federal assistance practices in fostering state-level abilities to support communities

Re: Prevention Prepared Communities

• A common set of risk factors is predictive of a range of negative outcomes including academic failure, aggression, delinquency, substance abuse, and violence.

• Mental, emotional, and behavioral problems tend to co-occur.• Intervening early and throughout a young person’s

development can positively alter his/her life trajectory. • Prevention programs that reach youth in a range of settings

have a stronger impact than those limited to only one setting. • Many prevention practices are effective but have not been

organized, purchased or delivered with sufficient intensity, comprehensiveness or duration to achieve their potential on a large-scale.

Prevention of Psychotic Disorders(W. McFarlane, 2009)

• Early Detection and Intervention

• Data re functioning as effect of number of psychotic episodes

• Effects of untreated initial psychosis

• Reducing incidence of major psychotic episodes in defined population by early detection and intervention

• Professional and public education

• Inter-professional collaboration

Results

• Incidence effects: 50% reduction in risk

• Cases not converted to psychosis: 77%

• Global assessment functioning in 12 months: improved

• Formal/informal providers trained in early warning signs of psychosis

Prevention Service Definitions?

• Examples??

• Evidence-based parenting training for parents/families in high-risk situations

• Home visiting

• SBIRT initial screen

• Risk assessment for children in primary care

Surveillance: Prevalence of Serious Emotional Disorders among Children

• SAMHSA collaboration with CDC/National Center for Health Statistics

• National Health Interview Survey (NHIS)

– birth to elderly; Strengths/Difficulties Questionnaire ages 4-17; annual household survey; state level data

• Calibration Study to determine diagnoses of SED for children

• Anticipate findings starting in 2011