CrisisServicesProject 032916 FindingsRecommendations

IMPROVING CRISIS SERVICES FOR CALIFORNIA’S CHILDREN AND YOUTH DRAFT Staff Project Summary, Findings and Draft Recommendations for Stakeholder Review and Comment DRAFT Provide vision and leadership, in collaboration with government and community partners, clients, and their family members, to ensure Californians understand mental health is essential to overall health. The MHSOAC holds public mental health systems accountable and provides oversight for eliminating disparities, promoting mental wellness, recovery and resiliency, and ensuring positive outcomes for individuals living with serious mental illness and their families. Improving Crisis Services for California’s Children and Youth Problem Statement For many children and families, accessing crisis services may be their first introduction to the mental health system. Addressing the needs of children in crisis is often more complex and challenging than it is for adults. It requires coordinating care across multiple child serving agencies with at times competing or contradictory goals. Multiple funding streams and regulations with restrictive eligibility criteria and overly burdensome reporting requirements, present real challenges to effectively meeting the needs of the whole child while building on their natural supports. Getting crisis care ‘right’ is critical to health outcomes overall and to the individual’s and family’s recovery and ongoing engagement with mental health services. While considerable progress has been made in this area over the past decade, there remain high levels of unmet needs within the children’s mental health system of care generally and crises services in particular. One of the tragic consequences of these unmet needs is that far too often families and caregivers of children, at times as young as 5 or 6 years of age, must turn to law enforcement and emergency departments that are ill equipped to address mental health crises for children. The experience of waiting for hours or days in a noisy, chaotic and frightening emergency department, during what is already an extremely stressful and vulnerable time for children and their families, can dramatically increase the mental and emotional trauma inherent in a crisis situation. Long waiting periods in emergency rooms often followed by extended ambulance rides to acute psychiatric—facilities at times several hundreds of miles away from the child’s home— underscores the fact that the “fail first” approach to mental health care remains a reality in many communities throughout California and provides a strong indicator of the serious work that remains for both private and publicly-funded mental health services. Nearly 40,000 California children ages 5-19, or 5 of every 1,000, were hospitalized for mental health issues in 2014.1 Since 2008, mental health needs have accounted for the largest share of hospital admissions of children ages 0-17 in California.2 In Fiscal Year 2013-14, children in California age 0-17 experienced more than 23,000 involuntary 72-hour detentions for evaluation and treatment.3 The continued lack of sufficient cost-effective, compassionate, recovery-based crisis services in many communities represents a substantial gap in the continuum of care for children and youth with mental health needs. The inability of many communities to provide medically-necessary care to children in crisis in the least restrictive setting possible also exposes the State to costly and burdensome legal interventions, which have already occurred in other jurisdictions throughout the nation. California has the opportunity to learn from evidence-based models of comprehensive continuums of crisis service implemented in other jurisdictions. With continued attention and focused effort, California will be able to address the remaining challenges and barriers and become a leader in ensuring that the crisis mental health needs of all children and their families are met, regardless of who they are or where they live. Improving Crisis Services for California’s Children and Youth Project Description In 2015, the Mental Health Services Oversight & Accountability Commission (MHSOAC) initiated a project to understand the state of children’s mental health crisis services, document challenges, identify effective service delivery models, and advance specific policy, funding and regulatory changes to improve service quality and outcomes. To ensure consistency with the direction and intent of the MHSOAC, a subcommittee of the Commission, chaired by Commissioner John Boyd, guided all phases of the project. An advisory workgroup was charged with defining crisis services; exploring the role of these services within a continuum of care that is prevention focused and recovery oriented; identifying challenges, barriers, opportunities and best practices; and developing recommendations to improve access, service coordination and outcomes. Over the course of several months, Commission members heard from parents, consumers, policy makers, advocates, and service providers to gain a broad understanding of the real world experience of children and youth in crisis. Commission members also visited a number of service providers throughout the state and learned from both the successes and ongoing challenges faced by individuals and organizations working in this area. Informed by the knowledge, experience and expertise of the advisory workgroup, MHSOAC staff conducted an extensive review of published literature, training initiatives and related material on children’s crisis service models. The project was informed by a review of national guidelines and specific state models of successful system responses to children’s mental health crises services. This review provided a foundation for the development of specific action oriented policy and practice recommendations. Findings and Recommendations One theme that consistently emerged throughout this project was the importance of implementing a comprehensive continuum of crisis services that focuses specifically on meeting the needs of children, youth, teens and families at each potential phase of a mental health crisis. To effectively support children and their families/caregivers while also reducing the likelihood of trauma, crisis services must have the ability to increase or decrease the intensity of interventions, across a range of home, community and residential services in response to the needs of children and their unique context. Crisis service providers must have the capacity to respond rapidly to a variety of community settings, 24 hours per day and 7 days per week, and remain with the child and family until the crisis is resolved or a determination is made that a higher level of intervention is required. While not all mental health crises can be addressed in a community setting, it is critical to have a range of available interventions with emergency department and/or acute psychiatric hospitalization representing the last alternative after all other efforts and resources along the continuum have been exhausted or determined inappropriate for resolving the crisis. Although several communities throughout California have made significant progress in developing specific program components and services designed to respond to children experiencing a mental MHSOAC 2 | P a g e Improving Crisis Services for California’s Children and Youth health crisis, this project identified no county that has successfully built out the full continuum of services required to fully meet the needs of children and families in crisis. This lack of a fully developed continuum of crisis services places an exceptional burden on emergency rooms and the limited number of acute psychiatric beds available across the state. The project findings and recommended actions outlined below are intended to support the continued “buildout” of a viable, comprehensive continuum of crisis services and ensure access for all children and youth regardless of who they are or where they live. Finding 1: Too many California children and youth are not receiving the crisis services they need. California’s delivery system for children in crisis is inadequate. As a result, too many children and their caregivers are often forced to turn to law enforcement, emergency rooms and acute psychiatric facilities at times of crises. This reliance on law enforcement and emergency rooms for crisis services is expensive and often leads to a mismatch between the services children need and what they receive. Recommendation 1: California should establish clear and compelling standards for crisis services that ensure that all children facing a mental health crisis receive the services they need in an age- appropriate and timely manner. Standards should be established for both private and publicly- funded mental health plans and should include:  Reasonable timeframes for access to care.  Age-appropriate services for children, youth, and transition-age youth.  Definitions of “medically necessary” care.  A continuum of integrated services that includes mobile services where needed.  Safety plans for services following a crisis.  Consumer and family support that reflects goals of recovery and wellness. Finding 2: Fragmented mental health crisis services undermines care coordination and outcomes for children and families. Rural counties in particular face unique challenges in providing comprehensive community-based crisis services to children and youth. Recommendation 2: The Department of Health Care Services, as California’s lead mental health agency, must work with counties, providers, health plans and others to address the following challenges:  Explore funding options to expand California’s investment in crisis care, prevention, early intervention and related services. Funding options should include: o Strategies for cost avoidance and savings that can result in redirection of existing funds and the use of growth funds toward crisis care. o Securing private-sector insurance coverage for some or all crisis-related services. MHSOAC 3 | P a g e Improving Crisis Services for California’s Children and Youth o Clarifying when and where Medi-Cal coverage is available to cover the costs of care. o Partnering with other local agencies, including child welfare, juvenile justice, local education agencies and others to leverage available resources where feasible.  Identify best practices for prevention and early intervention, and disseminate those best practices through a training and technical assistance strategy. Best practices should include: o Regional approaches to providing a continuum of crisis services, particularly for rural, sparsely populate, and isolated communities. o Tailored approaches to meeting the needs of California’s diverse populations. o Expanded use of mobile, crisis stabilization, short-term residential programs. o Development of a dynamic service registry that allows counties and providers to more effectively use existing services. o The development and deployment of individualized treatment teams that are multi- disciplinary, involve children and their families/caregivers, and incorporate the perspectives of mental health, education, and other relevant service providers. Finding 3: California lacks a statewide system of accountability and quality improvement to ensure all children and youth have access to crisis services when and where they need them. That system should be designed to document both excellence and gaps in care, and to allow the public and policy makers to understand how effective programs and policies are. Recommendation 3: The Governor and Legislature should establish an outcome and accountability reporting system, under the authority of the Department of Health Care Services, with guidance and monitoring from the Oversight and Accountability Commission, for crisis services in California.  That system should be integrated into the Department’s Performance Outcome System and related data and reporting systems. Key indicators should be developed by the Department through a public process that involves the Commission, the Mental Health Planning Council, counties, providers, youth advocates and others.  The Department should provide to policymakers and the public an annual report on crisis services that includes key indicators for each county and the state as a whole, such as: o The number and demographic characteristics of children, youth and transition-age youth who access crisis services, o Delays in access to care, o Proximity of crisis services access relative to a child’s home, school and family, MHSOAC 4 | P a g e Improving Crisis Services for California’s Children and Youth o Measures of the duration of crisis services utilization and of repeated use of crisis services, and o Efforts to improve these indicators.  The Commission should establish standards for the three-year plans required under the MHSA that can be integrated into county Medi-Cal and related plans, and develop a strategy for monitoring those plans that empowers the public, local officials and others to monitor the quality of county plans and assess progress in improving community mental health services, including crisis services. Next Steps Following review and comment from the advisory workgroup and other interested stakeholders, the full project report with updated findings and recommendations will be presented to the Commission during the regularly scheduled public meeting in May 2016. Based on the outcome of that meeting, project staff will develop specific implementation plans for policy, regulatory, and/or funding recommendations approved by the Commission. It is anticipated that the advisory workgroup will continue to play a vital role in the implementation of any approved practice or policy directions. 1 Hospitalizations for Mental Health Issues, by Age Group (2014), Kidsdata.org 2 Hospital Discharges by Primary Diagnosis (2014), Kidsdata.org 3 California Involuntary Detentions Data Report, Fiscal Year 2013‐14, California Department of Health Care Services‐Mental Health Services Division. MHSOAC 5 | P a g e