ILCHF Symposium, Children's Mental Health Initiative, Building Systems of Care Community by Community

1. Outcomes of Systems of Care
Shannon Robshaw, MSW
Senior Advisor for System Design and Implementation
The Technical Assistance Network for Children’s Behavioral Health
The Institute for Innovation and Implementation
University of Maryland, School of Social Work
December 6, 2018

2. •13-20% of children and adolescents have a diagnosable mental, emotional,
or behavioral disorder, and this costs the public $247 billion annually.
•50% of adult mental illness occurs by age 14; 75% by age 24
•1 in 10 children in the US suffer from a serious emotional disturbance (SED)
•In 2015, suicide was the third leading cause of death among youth ages 10-
14 and the second leading cause of death between ages 15-34.

3. “…mental health problems in youth are likely to
become one of the main public health challenges
of the twenty-first century.”
- WHO

4. Mental Health Disorders are the MOST
Expensive Conditions in Childhood
• While children who receive mental health services are
less than 10% of the overall Medicaid child
population, they account for 38% of all Medicaid child
expenditures (Pires, Grimes, Allen, Gilmer, & Mahadevan, 2013).
• The highest expenditures for all types of insurance
and conditions (including physical conditions) among
children 0 – 17 were for the treatment of mental
disorders: Costing $13.8 billion in 2011 (AHRQ, 2015).

6. Expense is driven by use of
behavioral health, not physical
health care
Pires,S.,Gilmer,T.,McLean,J.andAllen,K.2018. FacesofMedicaidSeries:Examining
Children’sBehavioralHealthServiceUseandExpenditures:,2005-2011.
CenterforHealthCareStrategies:Hamilton,NJ.
Availableat:https://www.chcs.org/resource/faces-medicaid-examining-childrens-behavioral-health-service-utilization-expenditures/
Have mean expenditures of
$46,959
• BH expense: $36,646
• PH expense: $10,314
Children Using Behavioral Health Care in Medicaid with
Top 10% Highest Expenditures

7. Social
Determinants
of Health
Wraparound focuses across
life domains, including
social determinants of
health

8. Children and Youth
with Serious
Behavioral Health
Conditions Are A
Distinct Population
from Adults with
Serious and
Persistent Mental
Illness
Do not have the same high
rates of co-morbid physical
health conditions.
Have different mental health diagnoses (ADHD,
Conduct Disorders, Anxiety; not so much
Schizophrenia, Psychosis, Bipolar as in adults), and
diagnoses change often.
Are multi-system involved –
two-thirds typically are
involved with CW and/or JJ
systems and 60% may be in
special education – systems
governed by legal mandates.
Coordination with other children’s systems (CW, JJ,
schools) and among behavioral health providers, as
well as family issues, consumes most of care
coordinator’s time, not coordination with primary care,
though primary care coordination also important.
To improve cost and quality of care, focus must be on
child and family/caregiver(s) – takes time – implies
lower care coordination ratios and higher rates.
Pires, S. March 2013 Customizing Health Homes for Children with Serious Behavioral Health Challenges.
Human Service Collaborative. Washington, D.C.

9. Definition of a System of Care
• broad, flexible array of effective services and supports for a defined
population
• organized into a coordinated network, integrates care planning and
management across multiple levels
• culturally and linguistically competent
• meaningful partnerships with families and youth at service delivery,
management, and policy levels
• supportive policy and management infrastructure,
• data-driven.
Pires, S. (2010). Building systems of care: A primer, 2nd Edition. Washington, D.C.: Human Service Collaborative for
Georgetown University National Technical Assistance Center for Children’s Mental Health.

10. CMS/SAMHSA May 2013 Joint Information Bulletin
Intensive Care
Coordination:
Wraparound
Approach
Parent and Youth
Support Services
Intensive In-
Home Services
Respite
Mobile Crisis
Response and
Stabilization
Flex Funds
Trauma Informed Systems and
Evidence-Based Treatments
Addressing Trauma
https://www.medicaid.gov/federal-policy-guidance/downloads/cib-05-07-2013.pdf

11. National evaluation of
Children’s Mental
Health Initiative (CMHI)
• SAMHSA-funded initiative
• 106 sites initially funded from
2002 to 2010
• More than 134,000 children and youth have received services
• Data collected between October 2003 and December 2014 on
outcomes of children and youth receiving SOC services

12. Demographics of Study Participants, Grantees
Initially Funded 2002–2010
Gender (n = 15,793) Percentage
Male 62.5%
Female 37.5%
Poverty Status (n = 13,314) Percentage
Below Poverty 58.8%
At/Near Poverty 15.2%
Well Above Poverty 26.0%
Age (n = 15,785)
Mean Age 11.20 (SD = 5.0)
(n = 15,669)

13. Most Common Diagnoses of Children Served by
Grantees Initially Funded 2002–2010
Diagnosis (n = 13,560) Percentage*
Mood Disorders 37.5%
Attention-Deficit/Hyperactivity Disorder 35.8%
Oppositional Defiant Disorder 22.8%
Adjustment Disorders 13.6%
Anxiety Disorders 9.3%
PTSD/Acute Stress Disorder 8.9%
Disruptive Behavior Disorder 8.3%
Substance Use Disorders 7.6%
Early Onset Psychosis 1.5%
Diagnoses based on DSM–IV criteria.
*Because children may have more than one diagnosis, percentages for diagnoses may
sum to more than 100%.

14. The National
Evaluation’s ROI Study
• Youth served in systems of care are less likely to
receive psychiatric inpatient services. From the 6
months prior to intake to the 12-month follow up,
the average cost per child served for inpatient
services decreased by 42%.
• Youth in systems of care are less likely to be
arrested, resulting in a 55% reduction in average per-
youth arrest-related costs.

15. Enrollment in a SOC resulted in
significantly improved clinical outcomes
• Improvement in behavioral & emotional symptoms
• Fewer internalizing and externalizing symptoms
• Improvements in levels of clinical impairment
• Fewer suicidal thoughts & attempts

16. Clinical Outcomes
As measured by the Child Behavior Checklist (CBCL), upon entering
services, 76.1% of children and youth had significantly elevated levels of
symptoms. This number fell to 53.8% in 6 months after beginning
services, and further to 48.7% after 12 months.
• Internalizing symptoms: The number of children and youth who had
significantly elevated levels of internalizing symptoms such as
depression and anxiety was 61.0% at entry into services, but fell to
51.7% after 6 months and 47.4% after 12 months.
• Externalizing symptoms: For externalizing symptoms, such as
aggression and rule-breaking, the proportion of children and youth who
had significantly elevated symptoms fell from 74.7% at intake to 64.6%
after 6 months and further to 60.3% after 12 months.

17. Clinical Outcomes
• Clinical impairment: Upon entering services, 76.8% were rated as
showing significantly high levels of impairment on the Columbia
Impairment Scale (CIS). This was reduced to 67.5% after 6 months and
63.8% after 12 months of services.
• Suicidal thoughts: Upon entering services, 28.4 % of children and
youth experienced suicidal thoughts in the previous 6 months. After
receiving SOC services, this proportion fell to 19.5% after 6 months and
16.2% after 12 months.
At entry into services, 8.5% of children and youth had made a suicide
attempt in the previous 6 months. After 6 months receiving services, this
rate fell to 4.8% after 6 months and 4.0% after 12 months.

18. After enrollment in a SOC, youth were
less likely to be arrested

19. Juvenile Justice Outcomes
Delinquency Survey, Revised (DS-R)
Intake through 24-month follow-up.

20. After enrollment in a SOC, children were
treated in less restrictive levels of care

21. Least Restrictive Care
0%
5%
10%
15%
20%
25%
Intake 6 Months 12 Months 18 Months 24 Months
Residential Camp (n = 147) Inpatient Hospitalization (n = 148)
Residential Treatment Center (n = 147) Therapeutic Group Home (n = 147)
Therapeutic Foster Care (n = 147)
Multi-System Services Contacts (MSSC)Intake through 24-month follow-up.
* Inpatient Hospitalization: p < .05. All other trend lines: n.s.

22. Enrollment in a SOC resulted in
improved educational outcomes
• Higher rates of educational achievement
• Improved school attendance
• Fewer suspensions & expulsions
• Higher rates of educational achievement
• Improved school attendance
• Fewer suspensions & expulsions

23. Education Outcomes Outcomes
• School Attendance: 53.8% improved after enrollment in SOC (intake
to 24-month follow-up) (n = 394)
• School Performance: 48.2% improved (n = 251)
Based on Education Questionnaire, Revised (EQ-R

24. Systems of Care Work
• Reduced behavioral & emotional problems
• Improved functioning in school & in the community
• Increased behavioral & emotional skills
• Reduced suicidal ideation & attempts
• Reduced substance use problems
• Improved ability to build relationships

25. Cost savings are realized
• Fewer out-of-home
placements/diversion from
higher levels of care
• Fewer ER visits
• Better school-related outcomes
• Fewer arrests
• Greater capacity for caregivers
to work

26. • National evaluation of the CMHI that funded over 250
local SOCs since its start in 1993 with 6-year SOC
development grants
• Evaluation of the Medicaid Psychiatric Treatment Facility
Psychiatric Residential Treatment Facilities (PRTF) Waiver
Demonstration
• Published literature
• State and communities that have conducted their own
analyses
Data Sources
26

27. • Serve population of children and youth with serious and
complex disorders; priority on risk of out‐of‐home placement
• Array of home‐ and community‐based treatment services and
supports
• Individualized, wraparound approach
• Intensive care management at low ratios
• Goal of diversion and/or return of children and youth from
inpatient and residential treatment settings
• Evidence of positive clinical and functional outcomes
• Some may not use the term “SOC” but approach reflects SOC
characteristics
Common Characteristics
of the SOCs
27

28. • Federal Children’s Mental Health Initiative (CMHI)
launched in 1993 to fund communities, tribes, and
territories to implement the system of care (SOC)
approach
• National evaluation of the CMHI found
– Positive outcomes for children and families
– Improvements in systems and services
– Better investment of limited resources
• Results have led to efforts to expand implementation of
the approach so that more children and families benefit
System of Care Outcomes
28

29. Examples: National CMHI Evaluation
Outcome Cost Savings
Reduced
Inpatient Use
• Average cost per child reduced by 42%
• $37 million saved when applied to all children/youth in funded SOCs
Reduced ER Use • Average cost per child reduced by 57%
• $15 million saved when applied to all children/youth in funded SOCs
Reduced Arrests • Average cost per child reduced by 39%
• $10.6 milling saved when applied to all children/youth in funded SOC
Reduced School
Dropout
• Fewer school dropouts in SOCs (8.6%) than national population (20%)
• Potential $380 million saved when applied to all children/youth in
funded SOCs
o Based on monetizing average annual earnings/earnings over
lifetime
Reduced
Caregiver
Missed Work
• Estimated 39% reduction in average cost of lost productivity
o Based on imputed average daily wage of caregivers
29

30. Examples: PRTF Evaluation
9 States Cost Savings
Evaluation of Medicaid
Psychiatric Residential
Treatment Facilities (PRTF)
Waiver Demonstration in 9
States
• Waiver expenditures cost 32% of services
provided in PRTF; home‐ and community‐
based services with wraparound process
• Average savings of 68%
• Average per child savings of between
$35,000 and $40,000
30

31. Community Cost Savings
Wraparound
Milwaukee
• $3,200 average total all‐inclusive cost per child per month vs
$6,083 group home, $8,821 correctional facility, $9,460
residential treatment, $39,100 inpatient
• Reduced use of psychiatric hospitalization by 96% and
residential treatment center placements by 87% in Milwaukee
County from 1996 to 2012
• Reduced costs by over 50% ($8,000 to $3,450 per child per
month) since inception; attributed to reduced utilization of
inpatient and residential treatment
• Nearly all youth at risk of juvenile correctional placement are
enrolled (80% have diagnosed mental health condition)
• Average number of youth in juvenile correction placements
declined; costs to the county declined by 37% from 2007 to
2102; nearly $9 million savings
31

32. 32
Community Estimated Costs Avoided By County
Wraparound
Milwaukee
• In 1996, an average of 337 youth placed in residential
treatment centers
• Factored in modest increases in the number of youth
placed/cost increases/projected potential expenditures by
child welfare and juvenile justice of $85 million from 1996 to
2012 without Wraparound Milwaukee
• With Wraparound Milwaukee, placement costs were only $10
million in 2012
Cost avoidance of about $75 million

33. 33
Children’s System of Care Objectives
To Help Youth Succeed…
At Home
In School
In the Community
Successfully living with their families and reducing the
need for out-of-home treatment settings.
Successfully attending the least restrictive and most
appropriate school setting close to home.
Successfully participating In the community and
becoming independent, productive and law-abiding
citizens.
New Jersey

34. Client
Case
Placement
Language Is Important
New Jersey

35. 35
Service Array Expansion to Reduce Use of Deep
End Services
Low
Intensity
Services
Out of Home
Out
of
Home
Intensive In-
Community
Wraparound – CMO
Behavioral Assistance
Intensive In-Community
Lower Intensity Services
Outpatient
Partial Care
After School Programs
Therapeutic Nursery
Prior to Children’s System of Care Initiative Today
New Jersey

36. Out of home treatment is an intervention,
not the final destination!
Key points to remember….
•Removing a child from their natural environment is a life altering
decision
•The pursuit of out of home treatment is a Child Family Team (CFT)
decision that should be made with clear purpose AND expectations
Out of Home Treatment in a SOC
New Jersey

37. Building In State Capacity and Increasing
Community Based Services
New Jersey

38. • High Family Satisfaction
• RTC length of stay decreased by 25%
• Closure of state child psychiatric hospital and state operated RTC’s
• Over 94% of youth accessing Mobile Response stay in current living
situation
• 250% Increase in families accessing Mobile Response since 2004
Youth involved with juvenile justice have access to System of Care services
• NJ was maintaining 17 county juvenile detention centers. Today there
are 11
• Decline in juvenile detention average daily population by 60% since 2004
• 6,000 less youth admitted to detention in NJ since 2004
New Jersey

39. • Oklahoma Systems of Care (OKSOC) began in 2 communities in 1999.
• State and federal financing and the active sponsorship of the Oklahoma
Department of Mental Health and Substance Abuse Services (ODMHSAS)
have helped OKSOC expand statewide to all 77 counties and increase the
number of families and youths served.
• OKSOC supports, maintains, and grows local systems of care communities
by providing infrastructure, training and technical assistance, and staff
professional development.
Oklahoma

40. CHILDREN’S HEALTH HOME
Child & Family SOC Team
I
N
T
E
G
R
A
T
I
O
N
PCMH
Access to physician
Consultation with HH
EPSDT screening
Immunization
Referral to specialty care
Transition to/from
hospital care
Linkage
Assessment
Specialty
BH Services
Community
Support
Housing
Transportation
Food
Link
Engage
Advocate
Support
Schools
Community
Safety
Placement
OJA
Team Approach
One Care Plan
Team Approach
One Care Plan
Support
OKDHS
Safety
Placement(s)
Permanency
Wraparound
Psychiatrist
Medication Management
Therapy
Family Support
Wellness Activitiess
IDEA
Transitions
Education
Specialty
Healthcare
Oklahoma

42. Wraparound Outcomes

43. Wraparound Outcomes

44. Wraparound Outcomes

45. Wraparound Outcomes

46. The Louisiana Coordinated System of Care (CSoC) began March 1,
2012 with the goals of:
 Reducing state’s costs by leveraging Medicaid and other funding
sources as well as increasing service effectiveness and reducing
duplication across agencies
 Reducing out-of-home placement for children currently in
placement and future admissions of children and youth with
significant behavioral health challenges and co-occurring disorders
 Improving the overall outcomes of children and their caregivers
Louisiana

47. Decreased utilization of costly restrictive settings
 Only 4.7% of the children enrolled in CSoC spent any days in an
inpatient hospital setting, with an average length of stay of only 6
days.
 54.5% decrease in the use of the emergency room
 91% of the children discharged or dis-enrolled from the program are
in a home and community based setting.
Louisiana
Magellan 2018

48. Significant improvements in overall functioning
• Over the average length of enrollment (12 months), CSoC children
demonstrated significant improvements in overall functioning.
 73% of the children discharged demonstrated improvements in clinical
functioning
 91% of members reporting positive overall satisfaction with wraparound
process
 87% of members reporting positive satisfaction with progress since
starting CSoC
Louisiana
Magellan, 2018

49. 49
Does wraparound work?
Evidence from Nine Published Controlled Studies is Positive
Study Target population Control Group Design N
1. Hyde et al. (1996)* Mental health Non-equivalent comparison 69
2. Clark et al. (1998)* Child welfare Randomized control 132
3. Evans et al. (1998)* Mental health Randomized control 42
4. Bickman et al. (2003)* Mental health Non-equivalent comparison 111
5. Carney et al. (2003)* Juvenile justice Randomized control 141
6. Pullman et al. (2006)* Juvenile justice Historical comparison 204
7. Rast et al. (2007)* Child welfare Matched comparison 67
8. Rauso et al. (2009) Child welfare Matched comparison 210
9. Mears et al. (2009) MH/Child welfare Matched comparison 121
*Included in 2009 meta-analysis (Suter & Bruns, 2009)

50. Outcomes of wraparound (9 controlled, published studies to date;
Bruns & Suter, 2010)
• Better functioning and mental health outcomes
• Reduced recidivism and better juvenile justice outcomes
• Increased rate of case closure for child welfare involved
youths
• Reduction in costs associated with residential placements
50

51. Lower Costs and Fewer Hospital and Residential Stays
Wraparound Milwaukee (Kamradt and Jefferson, 2008)
• Reduced psychiatric hospitalization from 5000 to less than 200 days annually
• Reduced average daily residential treatment facility population from 375 to 90
Controlled study of Mental Health Services Program for Youth in Massachusetts (Grimes, 2011)
• 88% of overall program days for youth were spent at home
• Hospitalization rates during 12 mos of enrollment were reduced 70% compared to the 12 mos prior to enrollment;
• Residential treatment settings use declined by 81% during the same period
CMS Psychiatric Residential Treatment Facility Waiver Demonstration (Urdapilleta et al., 2011)
• Costs were 32% less on average across 9 states compared to comparable PRTF population through reduction in residential care and increase in home and
community services, including Wraparound
• Average per capita saving by state ranged from $20,000 to $40,00
New Jersey (Hancock, 2012)
• Saved over $30 million in inpatient psychiatric expenditures over 3 years
Maine (Yoe, Bruns, & Ryan, 2011)
• Reduced net Medicaid spending by 30%, even as use of home and community services increased
• 43% reduction in inpatient and 29% in residential treatment expenses
Los Angeles County Dept. of Social Services
• Found 12 month placement costs were $10,800 for Wraparound-discharged youths compared to $27,400 for matched group of residential treatment center
youths

52. In addition to using fewer hospital days and costing less, Massachusetts Mental Health Services Program for
Youth enrollees and their families were engaged in their care and showed significant clinical improvement.
Clinical results and care experience findings across sites include:
•Average overall improvement at 18 months in CAFAS scores was 22 pts., indicating clinical change
•CAFAS Thinking score at 18 months improved 51%; Community Risk improved 31%
•Lethality score at 24 months improved 29%; CGAS improved 17% at 24 months
Improvements in Clinical and Functional Outcomes
Wraparound Milwaukee: 60% reduction in recidivism rates for delinquent youth from one year prior
to enrollment to one year post enrollment and school attendance for child welfare-involved children
improved from 71% days attended to 86% days attended
Marion County, Indiana (Indianapolis): Reduced recidivism (youth are 78% less likely to return to any
child-serving agency)
Improved scores on CAFAS, CBCL, BERS
Improved school attendance and academic performance
New Jersey: Improvements in clinical and functional status using CANS

53. Massachusetts Mental Health Services Program for Youth:
• Family Centered Behavior Scale indicated 96% of families felt their MHSPY Care Manager
“helps them expect good things in the future for themselves and their children.”
• Parents reported being “Satisfied” or “Very Satisfied” 86% of the time with the help they
received
Strong Family and Youth Satisfaction
Marion County, Indiana:
• 86% of families reported that services were helpful
• 82% of youth reported that services were helpful
• 86% of families reported that services reflected their family’s strengths and culture
Rotto, K. Choices, Inc. 2005
Wraparound Milwaukee:
• 91% of families/caregivers felt they and their child were treated with respect
• 91% of families felt staff were sensitive to their cultural, ethnic and religious needs
• 72% felt there was an adequate crisis/safety plan in place
• 64% felt Wraparound empowered them to handle challenges situations in the future

54. Outcomes Depend on Implementation:
“Full Fidelity” is Critical
• Research shows
• Provider staff whose families experience better outcomes score higher on
fidelity tools (Bruns, Rast et al., 2006)
• Wraparound initiatives with positive fidelity assessments demonstrate
more positive outcomes (Bruns, Leverentz-Brady, & Suter, 2008)
• Much of Wraparound implementation is in name only
• Don’t invest in workforce development such as training and coaching to
accreditation
• Don’t follow the research-based practice model
• Don’t monitor fidelity and outcomes and use the data for CQI
• Don’t have the necessary support conditions to succeed (e.g., fiscal
supports, comprehensive service array)
Bruns, E. NWI

55. Demonstrated Effectiveness of SOCs
Improve the lives of children and youth
• Decrease behavioral and emotional problems
• Decrease suicide rates
• Decrease substance use
• Decrease involvement with juvenile justice
• Improve school attendance and grades
• Increase stability of living situations
Improve the lives of families
• Decrease caregiver strain
• Increase capacity to handle their child’s challenging behavior
• Increase ability to work
55

56. Demonstrated Effectiveness of SOCs
Improve services
• Expand services to a broad array of home and
community‐based services
• Customize services with an individualized, wraparound
approach
• Improve care coordination
• Increase family‐driven, youth‐guided services
• Increase cultural and linguistic competence of services
• Increase use of evidence‐informed practices
56

57. • Redeploy resources from higher cost restrictive services to
lower cost home‐ and community‐based services and
supports
• Increase utilization of home‐ and community‐based
treatment services and supports
• Decrease admissions and lengths of stay in out‐of‐home
treatment settings e.g. psychiatric hospitals, residential
treatment, juvenile justice, out‐of‐school placements
• Reduce costs across systems e.g. reduced out‐of‐home
placements in child welfare and juvenile justice facilities
with substantial per‐capita savings
Impact on Resource Investment
57

58. Questions?