OMHSAS Children’s OMHSAS Children’s Policy PresentationPolicy Presentation

Pennsylvania Council of Children, Pennsylvania Council of Children, Youth and Family ServicesYouth and Family Services

February 21, 2008February 21, 2008

Three PresentationsThree Presentations

BudgetBudget Children’s PrioritiesChildren’s Priorities Youth and Family Teams/High Youth and Family Teams/High

Fidelity WraparoundFidelity Wraparound

The Rendell Administration's The Rendell Administration's Major Budget InitiativesMajor Budget Initiatives

Implement the Implement the Protecting Our Progress Protecting Our Progress economic stimulus planeconomic stimulus plan Reduce Reduce property taxesproperty taxes Make needed investments in Make needed investments in educationeducation Implement Implement Prescription for PennsylvaniaPrescription for Pennsylvania Achieve greater Achieve greater energy independenceenergy independence Make Pennsylvania a strong Make Pennsylvania a strong economic competitoreconomic competitor Rebuild Pennsylvania’s Rebuild Pennsylvania’s infrastructureinfrastructure Maintain the Maintain the safety netsafety net Move people off welfareMove people off welfare into the labor force into the labor force Manage and Manage and reduce the growing prison populationreduce the growing prison population Protect our Protect our environmentenvironment

Higher Education

7%

Debt Service3%

Other DPW Human Service

Programs17%

Medical Assistance GF Share

20%

Pre K-12 Education

35%

All Other12%

Corrections6%

2008-09 General Fund Expenditures

The 2008-09 General Fund budget is $28.3 billion, an increase of $1.1 billion, or 4.2 percent,over 2007-08.

Spending onEducation, MedicalAssistance, other

Department of PublicWelfare programs,

Corrections and DebtService comprises 88

percent of totalGeneral Fundexpenditures.

Total GFExpenditures:$28.3 Billion

Department of Public WelfareDepartment of Public Welfare No one currently receiving services will lose eligibilityNo one currently receiving services will lose eligibility

Children will not experience any reduction in services Children will not experience any reduction in services

Pennsylvania will provide services for the growing number of Pennsylvania will provide services for the growing number of individuals and families who require Medical Assistanceindividuals and families who require Medical Assistance

Investing in Child Development Investing in Child Development & Early Learning& Early Learning

Child Care WorksChild Care Works Subsidized Child Care –expanded to serve an Subsidized Child Care –expanded to serve an

additional 2,600 children on a monthly basis to reach more than additional 2,600 children on a monthly basis to reach more than

235,000 children annually.235,000 children annually.

Keystone STARSKeystone STARS – expanded to assure quality early learning – expanded to assure quality early learning

experiences for more than 171,000 children.experiences for more than 171,000 children.

Early InterventionEarly Intervention – expanded to serve 3,000 – expanded to serve 3,000 additional children additional children

from birth through age five and to maintain existing services for from birth through age five and to maintain existing services for

77,700 children 77,700 children

Nurse-Family PartnershipNurse-Family Partnership –expanded to serve approximately 240 –expanded to serve approximately 240

additional families to reach more than 4,200 families. additional families to reach more than 4,200 families.

National leader in developing National leader in developing services for persons with autismservices for persons with autism

Bureau of Autism ServicesBureau of Autism Services created in 2007 created in 2007 Developing practice model for children and familiesDeveloping practice model for children and families Awarded respite mini-grants to over 1,000 families Awarded respite mini-grants to over 1,000 families Laid groundwork for Adult Community Autism Laid groundwork for Adult Community Autism

Program (ACAP)Program (ACAP)

New for FY 2008-09New for FY 2008-09 $7.6 million for services for 400 adults in ACAP and $7.6 million for services for 400 adults in ACAP and

new Autism Waiver, bringing the total to 600new Autism Waiver, bringing the total to 600 Intensive training to build provider and clinical Intensive training to build provider and clinical

capacity and establish Bio-behavioral Unitscapacity and establish Bio-behavioral Units Support for Autism Parity bill Support for Autism Parity bill

OMHSAS: Guiding PrinciplesOMHSAS: Guiding Principles• The Mental Health and Substance Abuse Service system will provide The Mental Health and Substance Abuse Service system will provide

quality services that:quality services that: Facilitate recovery and resiliency for adults and childrenFacilitate recovery and resiliency for adults and children Are responsive to individuals’ unique strengths and needs Are responsive to individuals’ unique strengths and needs

throughout their livesthroughout their lives Focus on prevention and early interventionFocus on prevention and early intervention Recognize, respect, and accommodate differences as they relate to Recognize, respect, and accommodate differences as they relate to

culture/ethnicity/race, religion, gender identity and sexual orientationculture/ethnicity/race, religion, gender identity and sexual orientation Ensure individual human rights and eliminate discrimination and Ensure individual human rights and eliminate discrimination and

stigmastigma Are provided in a comprehensive array by unifying programs and Are provided in a comprehensive array by unifying programs and

funding building on natural and community supports unique to each funding building on natural and community supports unique to each individual and familyindividual and family

Are developed, monitored and evaluated in partnership with Are developed, monitored and evaluated in partnership with consumers, families and advocatesconsumers, families and advocates

Represent true collaboration with other agencies & service systemsRepresent true collaboration with other agencies & service systems

OMHSAS ObjectivesOMHSAS Objectives

Transform the children’s behavioral health system to a system that Transform the children’s behavioral health system to a system that

is family driven and youth guided.is family driven and youth guided.

Implementation of services and policy to support recovery and Implementation of services and policy to support recovery and

resiliency in the Adult Behavioral Health System resiliency in the Adult Behavioral Health System

Assure that behavioral health services and supports recognize and Assure that behavioral health services and supports recognize and

accommodate the unique needs of older adults.accommodate the unique needs of older adults.

OMHSAS: FY 2008-09 BudgetOMHSAS: FY 2008-09 Budget Community MH ServicesCommunity MH Services

$1.011 B total state and federal funds, net increase of $1.011 B total state and federal funds, net increase of

$7.577 M; state funds increase $10.937 M$7.577 M; state funds increase $10.937 M

NoNo Cost of Living Adjustment Cost of Living Adjustment

CHIPP funding of $11.515 M for the discharge of 166 CHIPP funding of $11.515 M for the discharge of 166

individuals from the state hospitalsindividuals from the state hospitals

Transfer of $10.847 M from Medical Assistance for Transfer of $10.847 M from Medical Assistance for

Structured Treatment ServicesStructured Treatment Services

Elimination of funding line item for Psychiatric Training Elimination of funding line item for Psychiatric Training

Services in Eastern PAServices in Eastern PA

OMHSAS: FY 2008-09 BudgetOMHSAS: FY 2008-09 Budget Drug and Alcohol ServicesDrug and Alcohol Services

FY 2008-09 Act 152 budget is $16.227 MFY 2008-09 Act 152 budget is $16.227 M BHSI IGT funding of $12.107 MBHSI IGT funding of $12.107 M BHSI funding is $45.300 M (MH: $20.130, D&A: $25.170)BHSI funding is $45.300 M (MH: $20.130, D&A: $25.170) NoNo Cost of Living Adjustment Cost of Living Adjustment

Sexual Responsibility and Treatment Program (Act 21)Sexual Responsibility and Treatment Program (Act 21) Implemented in April 2004 on the grounds of Torrance Implemented in April 2004 on the grounds of Torrance

State HospitalState Hospital Sixteen men are now being servedSixteen men are now being served SRTP program operation was transferred to the SRTP program operation was transferred to the

Commonwealth and operated by Torrance State Hospital Commonwealth and operated by Torrance State Hospital (July 1, 2006)(July 1, 2006)

OMHSAS Children’s PrioritiesOMHSAS Children’s Priorities

Some Guiding PrinciplesSome Guiding Principles

Trauma informed culture should serve as Trauma informed culture should serve as the background for all services to children the background for all services to children and adolescentsand adolescents

CASSP principles are assumed to be part CASSP principles are assumed to be part of the children’s Objectives and of the children’s Objectives and Supporting ProjectsSupporting Projects

Youth and Family Teams will lead to a Youth and Family Teams will lead to a transformation of the children’s behavioral transformation of the children’s behavioral health system.health system.

TransformationTransformation

Transform the children’s behavioral health system to a Transform the children’s behavioral health system to a system that is family driven and youth guided.system that is family driven and youth guided.

Establish an Institute to provide training, support and Establish an Institute to provide training, support and monitoring of Youth and Family Teams;monitoring of Youth and Family Teams;

Develop mechanism for Medicaid payment of Youth Develop mechanism for Medicaid payment of Youth and Family Team process;and Family Team process;

Begin process of implementing Youth and Family Begin process of implementing Youth and Family Teams throughout the Commonwealth. Teams throughout the Commonwealth.

Children’s Supporting Projects and Children’s Supporting Projects and ActionsActions

Create Home and Community Based Create Home and Community Based Alternatives to Residential TreatmentAlternatives to Residential Treatment Develop a “White Paper” addressing current Develop a “White Paper” addressing current

environment, needs and recommendations for environment, needs and recommendations for creating alternatives to the current residential creating alternatives to the current residential treatment system treatment system

Change existing rules to permit small group homes Change existing rules to permit small group homes and therapeutic housingand therapeutic housing

Enroll Multi Dimensional Treatment Foster Care as a Enroll Multi Dimensional Treatment Foster Care as a Medicaid funded serviceMedicaid funded service

Maintain data base on RTF utilizationMaintain data base on RTF utilization

Children’s Supporting Projects and Children’s Supporting Projects and ActionsActions

Partner with Education to support the development of Partner with Education to support the development of effective school based supports and interventionseffective school based supports and interventions Have OMHSAS Children’s Advisory develop Have OMHSAS Children’s Advisory develop

“White Paper” on school based behavioral “White Paper” on school based behavioral health serviceshealth services

Engage youth to get their perspective on Engage youth to get their perspective on school based behavioral health servicesschool based behavioral health services

Continue to build the relationship with DOE Continue to build the relationship with DOE and collaborate on projects and collaborate on projects

Reduce admission to segregated programsReduce admission to segregated programs

Children’s Supporting Projects and Children’s Supporting Projects and ActionsActions

Create Behavioral Health competency to honor the Create Behavioral Health competency to honor the strengths and address the unique individualized needs of strengths and address the unique individualized needs of children and adolescents:children and adolescents: In the child welfare systemIn the child welfare system In, or at risk of entering, the Juvenile Justice systemIn, or at risk of entering, the Juvenile Justice system In the drug and alcohol systemIn the drug and alcohol system With Fetal Alcohol Syndrome DisorderWith Fetal Alcohol Syndrome Disorder That are Deaf or Hard of HearingThat are Deaf or Hard of Hearing With Traumatic Brain InjuryWith Traumatic Brain Injury With Autism Spectrum Disorder or other Pervasive With Autism Spectrum Disorder or other Pervasive

Developmental DisorderDevelopmental Disorder With Physical DisabilitiesWith Physical Disabilities And infants and young childrenAnd infants and young children

Children’s Supporting Projects and Children’s Supporting Projects and ActionsActions

Develop strategies to address the needs of Develop strategies to address the needs of Transitional YouthTransitional Youth Support Youth involvement in the OMHSAS Advisory Support Youth involvement in the OMHSAS Advisory

CouncilCouncil Obtain Youth input in identifying needs, developing Obtain Youth input in identifying needs, developing

plans, implementing and monitoring service plans, implementing and monitoring service development for Transition Youthdevelopment for Transition Youth

Summarize OMHSAS Transition Pilot projectsSummarize OMHSAS Transition Pilot projects Identify existing initiatives in other agenciesIdentify existing initiatives in other agencies Work with OMHSAS housing planWork with OMHSAS housing plan

Children’s Supporting Projects and Children’s Supporting Projects and ActionsActions

Develop a process for identifying and implementing Develop a process for identifying and implementing evidence based practices; promising practices and evidence based practices; promising practices and culturally relevant practicesculturally relevant practices

Utilize the SAMHSA National Registry of Evidence Based Utilize the SAMHSA National Registry of Evidence Based Practice, the NASMHPD Research Institute, the National Blue Practice, the NASMHPD Research Institute, the National Blue Print initiative and other sources to identify evidence based and Print initiative and other sources to identify evidence based and promising practicespromising practices

Document the expansion of Multi Systemic Therapy, Functional Document the expansion of Multi Systemic Therapy, Functional Family Therapy and other evidence based practices in current Family Therapy and other evidence based practices in current practicepractice

Develop the Youth and Family Team process as the practice Develop the Youth and Family Team process as the practice model for children’s behavioral health to support evidence based model for children’s behavioral health to support evidence based practicepractice

Evidence Based PracticesEvidence Based Practices

Multisystemic TherapyMultisystemic Therapy Intensive In-Home Intensive In-Home

TherapyTherapy Functional Family Functional Family

TherapyTherapy Wraparound ServicesWraparound Services Therapeutic Foster CareTherapeutic Foster Care Family SupportFamily Support Parent Management Parent Management

TrainingTraining RespiteRespite

School Based ServicesSchool Based Services Medication GuidelinesMedication Guidelines Early Childhood ServicesEarly Childhood Services Trauma- Focused Trauma- Focused

InterventionIntervention

ICSIICSI

CommunityCommunity 52 new Home and Community Based 52 new Home and Community Based

programsprograms ResidentialResidential

17 accredited, 43 PRTF sites, 1,394 beds17 accredited, 43 PRTF sites, 1,394 beds 15 Non-accredited, 79 residential sites, 1,246 15 Non-accredited, 79 residential sites, 1,246

bedsbeds Total residential capacity to 3223 accredited Total residential capacity to 3223 accredited

and 1604 non-accredited bedsand 1604 non-accredited beds

Positive ImpactsPositive Impacts Inclusion of MultiSystemic Therapy and Inclusion of MultiSystemic Therapy and

Functional Family Therapy as MA eligible Functional Family Therapy as MA eligible servicesservices

Collaboration, including local team structures Collaboration, including local team structures between BH, C&Y and JJbetween BH, C&Y and JJ

Internal workgroup established to establish a Internal workgroup established to establish a framework for continuum of care and framework for continuum of care and stakeholder processstakeholder process

Higher penetration in services for adjudicated Higher penetration in services for adjudicated youth in non residential settingsyouth in non residential settings

Cross Systems monitoring of residential servicesCross Systems monitoring of residential services

Continuing ChallengesContinuing Challenges

Timeliness of evaluationsTimeliness of evaluations Coordination of referralsCoordination of referrals Local county relationshipsLocal county relationships Provider roleProvider role Quality of careQuality of care

OMHSAS-OCYF OMHSAS-OCYF Residential InitiativeResidential Initiative

Office of Children, Youth and Families (OCYF) and Office of Children, Youth and Families (OCYF) and OMHSAS have convened joint PRTF work groupOMHSAS have convened joint PRTF work group Retreat in October 2007 established joint work groupRetreat in October 2007 established joint work group Goal to promote community alternatives to Goal to promote community alternatives to

dramatically reduce use in three years dramatically reduce use in three years andand improve improve quality of remaining PRTF capacityquality of remaining PRTF capacity

Continuum Work Group is developing report to begin Continuum Work Group is developing report to begin dialogue with stakeholdersdialogue with stakeholders

Quality Management InitiativesQuality Management Initiatives Pay for PerformancePay for Performance

Work group examining a measure for RTFsWork group examining a measure for RTFs Tentatively has selected family involvementTentatively has selected family involvement Efforts underway to define and develop indicatorsEfforts underway to define and develop indicators

RTF Outcome PilotRTF Outcome Pilot Working with OCYFWorking with OCYF Exploring a web based system using standard report Exploring a web based system using standard report

mechanismmechanism July 1, 2008July 1, 2008

Youth and Family TeamsYouth and Family Teams

Applying High Fidelity WraparoundApplying High Fidelity Wraparound

2727

In PennsylvaniaIn Pennsylvania

We have a long history of collaboration and We have a long history of collaboration and programs to support children and their families.programs to support children and their families.

We do not have strong evidence of outcomes for We do not have strong evidence of outcomes for our efforts.our efforts.

We need to implement and support research We need to implement and support research proven approaches, such as…proven approaches, such as…

High Fidelity Wraparound.High Fidelity Wraparound.

High Fidelity WraparoundHigh Fidelity Wraparound A process for supporting youth and families A process for supporting youth and families

with complex behavioral health needswith complex behavioral health needs Defined by National Wraparound InitiativeDefined by National Wraparound Initiative 10 principles10 principles Four phases Four phases (engagement, plan development, (engagement, plan development,

implementation and transition)implementation and transition) Theory of Change: Theory of Change: Needs, self efficacy, Needs, self efficacy,

natural supports and an integrated plannatural supports and an integrated plan

What Does the Research Say?What Does the Research Say?

High Fidelity Wraparound can produce significantly better High Fidelity Wraparound can produce significantly better outcomes for children and families with significant needs outcomes for children and families with significant needs than traditional approaches:than traditional approaches:

Decreased restrictiveness of residential environmentsDecreased restrictiveness of residential environments Improved behavior and mental health symptomsImproved behavior and mental health symptoms Improved school and early care outcomesImproved school and early care outcomes Decreased family and child safety issues and risk Decreased family and child safety issues and risk

factorsfactors Increased family engagement and satisfaction with Increased family engagement and satisfaction with

servicesservices Increased family resources to support their own Increased family resources to support their own

childrenchildren

Impact on CAFAS Scores Impact on CAFAS Scores after 6 Monthsafter 6 Months

-50

-40

-30

-20

-10

0

10

Trad MH Services High FidelityWraparound

Low Fidelity thenCoaching

Chn

age

In C

AFA

S S

core

s

6 months

Impact on CAFAS Scores Impact on CAFAS Scores after 18 Monthsafter 18 Months

-70-60-50-40-30-20-10

010

Trad MH Services High FidelityWraparound

Low Fidelity thenCoaching

Chn

age

In C

AFA

S S

core

s

6 months 18 months

Phases of wraparoundPhases of wraparound

Time

Engagement and team preparation

Transition

Implementation

Plan development

Phases of wraparound planningPhases of wraparound planning

PhasePhase Ballpark rangeBallpark rangeEngagementEngagement Duration of phaseDuration of phase First 2 weeksFirst 2 weeks

Frequency of contactsFrequency of contacts 2 – 5 times/week2 – 5 times/week

IntensityIntensity 6 – 12 hours/week6 – 12 hours/week

Plan developmentPlan development Duration of phaseDuration of phase Weeks 3 and 4Weeks 3 and 4

Frequency of contactsFrequency of contacts 2 – 4 times/week2 – 4 times/week

IntensityIntensity 6 – 10 hours/week6 – 10 hours/week

ImplementationImplementation Duration of phaseDuration of phase Weeks 5 onWeeks 5 on

Frequency of contactsFrequency of contacts 2 – 3 times/week2 – 3 times/week

IntensityIntensity 3 – 6 hours/week3 – 6 hours/week

TransitionTransition Duration of phaseDuration of phase Last 2 monthsLast 2 months

Frequency of contactsFrequency of contacts 1 – 2 times/week1 – 2 times/week

IntensityIntensity 1 – 3 hours/week1 – 3 hours/week

The TeamThe Team

Bring informal and formal resource togetherBring informal and formal resource together Include family, friends, neighbors, service providers, Include family, friends, neighbors, service providers,

spiritual leaders, others who want to help spiritual leaders, others who want to help Include service providers, who fill important rolesInclude service providers, who fill important roles Unique to each familyUnique to each family Give everybody involved a chance to achieve consensus Give everybody involved a chance to achieve consensus

on what to doon what to do Value family and community resourcesValue family and community resources Can help isolated families get needed support that lasts Can help isolated families get needed support that lasts

as long as it's neededas long as it's needed

TrainingTraining

Train and Hope does not work Train and Hope does not work About behavior and system change About behavior and system change Not satisfaction with trainingNot satisfaction with training Research on information provision and trainingResearch on information provision and training Factors that influenceFactors that influence

Initial motivation and engagementInitial motivation and engagement System and organizational supportSystem and organizational support Organizational climate and controlOrganizational climate and control Methods of trainingMethods of training

Need for CoachingNeed for Coaching

Newly-learned behavior is crude compared Newly-learned behavior is crude compared to performance by a master practitioner.to performance by a master practitioner.

Newly-learned behavior is incomplete and Newly-learned behavior is incomplete and will need to be shaped to be most will need to be shaped to be most functional in a service setting.functional in a service setting.

Newly-learned behavior is fragile and Newly-learned behavior is fragile and needs to be supported in the face of needs to be supported in the face of reactions from consumers and others in reactions from consumers and others in the service setting.the service setting.

Fidelity Assessment / ImprovementFidelity Assessment / Improvement

Two leveled certification competency Two leveled certification competency based certification processbased certification process

Measures of compliance to the Measures of compliance to the wraparound phases and activitieswraparound phases and activities

Measures of fidelity to the wraparound Measures of fidelity to the wraparound processprocess

Use of the measures to guide ongoing Use of the measures to guide ongoing professional developmentprofessional development

Certification – Wraparound Certification – Wraparound PractitionerPractitioner

Goal: to define the basic skill sets that must be Goal: to define the basic skill sets that must be demonstrated to be considered a competent entry level demonstrated to be considered a competent entry level wraparound facilitator wraparound facilitator

Requirements include:Requirements include: Has received 3 hours of supervision/coaching per weekHas received 3 hours of supervision/coaching per week Has a professional development planHas a professional development plan Has demonstrated competency on wraparound process Has demonstrated competency on wraparound process

tools tools Has demonstrated competency on each of nine Has demonstrated competency on each of nine

practitioner toolspractitioner tools

Action PlanAction Plan

Community EducationCommunity Education Testing financing model in Allegheny Testing financing model in Allegheny

CountyCounty Request for County MH/MR Programs to Request for County MH/MR Programs to

be Early Implementersbe Early Implementers

Community Context and ReadinessCommunity Context and Readiness

Engaging key stakeholdersEngaging key stakeholdersCommitment to core wraparound Commitment to core wraparound

components components Feasibility assessmentFeasibility assessmentStaffing and supervision ratios / Staffing and supervision ratios /

assignmentsassignmentsPolicies, procedures and Policies, procedures and

documentation processesdocumentation processes Implementation planImplementation plan

Youth and Family InstituteYouth and Family Institute

Will provide training and certificationWill provide training and certification Will provide coachingWill provide coaching Will conduct on-going evaluation using the Will conduct on-going evaluation using the

Wraparound Fidelity IndexWraparound Fidelity Index Will continue to provide support for Will continue to provide support for

counties as they establish the Youth and counties as they establish the Youth and Family Team processFamily Team process

Will provide information and education Will provide information and education