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									         Transforming Children’s Mental Health
                   Care in America

                                                       Gary M. Blau, Ph.D.
                                           Child, Adolescent and Family Branch
                                              Center for Mental Health Services
April 20, 2006        Substance Abuse and Mental Health Services Administration
Secret Formula for Transformation

“I think you should be more explicit here in Step Two.”
Beginnings ~
    Child, Adolescent Service System Program (CASSP)
                         – 1984 –

 Comprehensive Community Mental Health Services Program
             for Children and Their Families
                         – 1993 –

                     Circles of Care
                        – 1998 –
                      Fiscal Year (FY) 2005 budget
Dollar ($) in million

                                         $106,000,000                                                    $106.0
$102                                                                                       $98.7
 $82                                                       $78.0
                           $60.0 $60.0








































                                                  System-of-Care Communities of the
Phase I (1993–1999)                                                                                       Phase IV (2002–2010)
California 5 (Riverside, San Mateo, Santa                                                    Fairbanks Native Association, AK
   Cruz, Solano, & Ventura Counties)

                                            Comprehensive Community Mental Health Services
                                                                                                             Glenn County, CA
Santa Barbara County, CA
Napa & Sonoma Counties, CA                                                                                        Monterey, CA
                                                                                                      Sacramento County, CA
                                                for Children and Their Families Program
Wai‘anae & Leeward, HI
Lyons, Riverside, & Proviso, IL                                                                              San Francisco, CA
Sedgwick County, KS                                                                                 Urban Trails, Oakland, CA
Southeastern Kansas                                                                                      Colorado (4 counties)
Maine (4 counties)
                                                                                                       Connecticut (statewide)
Baltimore, MD
Navajo Nation                                                                                                  Washington, DC
Las Cruces, NM                                                                                             Broward County, FL
Mott Haven, NY                                                                                                            Guam
Edgecombe, Nash, & Pitt Counties, NC                                                                                       Idaho
Bismarck, Fargo, & Minot, ND                                                                                         Chicago, IL
Southern Consortium & Stark County, OH
                                                                                                            Northern Kentucky
Lane County, OR
South Philadelphia, PA                                                                                 Southeastern Louisiana
Rhode Island 1 (statewide)                                                                                 Southwest Missouri
Charleston, SC                                                                                                    St. Louis, MO
Alexandria, VA                                                                                         Montana & Crow Nation
Vermont 1 (statewide)                                                                                       Albany County, NY
Milwaukee, WI
                                                                                                                Erie County, NY
Phase II (1997–2004)                                                                                              New York, NY
Birmingham, AL                                                                                          Cuyahoga County, OH
San Diego County, CA
                                                                                                           Choctaw Nation, OK
Hillsborough County, FL
Eastern Kentucky                                                                                        Oklahoma (5 counties)
Passamaquoddy Tribe, ME                                                                  Mid-Columbia Region (4 counties), OR
Detroit, MI                                                                                                         Puerto Rico
Sault Ste. Marie Tribe, MI                                                               South Carolina (3 counties & Catawba
St. Charles County, MO                                                                                                   Nation)
Lancaster County, NE
                                                                                                            El Paso County, TX
Nebraska (22 counties)
Clark County, NV                                                                                                   Ft. Worth, TX
North Carolina (11 counties)                                                                                  Phase V (2005–2011)
Sacred Child Project, ND
                                                                                                  Mississippi River Delta area, AR
Clackamas County, OR
Allegheny County 1, PA                                                                                            Butte County, CA
Rhode Island 2 (statewide)                                                                   California Rural Indian Health Board,
Travis County, TX                                                                                                          Inc., CA
Rural Frontier, UT                                                                                       Los Angeles County, CA
Vermont 2 (statewide)                                                                                            Placer County, CA
Clark County, WA
                                                                                                        Southeastern Connecticut
King County, WA
Wisconsin (6 counties)                                                                                        Sarasota County, FL
Northern Arapaho Tribe, WY                                                                                             Honolulu, HI
                                                                                                               McHenry County, IL
Phase III (1999–2006)
                                                                                                                 Augusta area, ME
Yukon Kuskokwim Delta Region, AK
Pima County, AZ                                                                                            Worcester County, MA
Contra Costa County, CA                                                                                         Ingham County, MI
United Indian Health Service, CA                                                                           Kalamazoo County, MI
Denver area, CO                                                                                            Minnesota (4 counties)
Delaware (statewide)                                                                                           Blackfeet Tribe, MT
West Palm Beach, FL
                                                                                                               Monroe County, NY
Gwinnett & Rockdale Counties, GA
Lake County, IN                                                                                          Mecklenburg County, NC
Marion County, IN                                                                                         Multnomah County, OR
Montgomery County, MD                                                                                     Allegheny County 2, PA
Worcester, MA                                                                                                   Beaver County, PA
Willmar, MN                                                                                             Rhode Island 3 (statewide)
Hinds County, MS
                                                                                                         Yankton Sioux Tribe, SD
New Hampshire (3 regions)
Burlington County, NJ                                                                                            Maury County, TN
Westchester County, NY                                                                                           Harris County, TX
North Carolina (11 counties)                                                                                 Wyoming (statewide)
Greenwood, SC
Oglalla Sioux Tribe, SD
Nashville, TN
Charleston, WV
~ Achieving the Promise:
Transforming Mental Health Care in America ~

“We envision a future when everyone with a mental
illness will recover, a future when mental illnesses can be
prevented or cured, a future when mental illnesses are
detected early, and a future when everyone with a mental
illness at any stage of life has access to effective
treatment and supports - essentials for living, working,
learning, and participating fully in the community.”
         The Federal Action Agenda
                             Key Points
   Mental illness & emotional          Improve interface between
    disturbances are treatable           primary care & mental health
   National Strategy for Suicide
                                        Focus on early intervention
                                        Expand “Science-to-Services
   Help states implement                agenda
    comprehensive state mental
    health plans                        Increase employment of
                                         people with psychiatric
   Mental health practice that is       disabilities
    culturally competent and
    evidence-based                      Information system to better
                                         manage services & improve
T = (V+B+A) x (CQI)2
Child, Adolescent & Family Level              Programs                                    Child, Adolescent & Family Level
• Create positive experience with services    • Children’s Mental Health Initiative       • Significant improvement in behavior &
  & supports                                  • Circles of Care                             emotional functioning of children
• Promote family strengths                    • Partnerships for Youth Transition         • Increased satisfaction with services
• Develop child & youth potential & well-     • Statewide Family Networks                 • Family & youth have a decision-
  being                                       • Child & Adolescent State Infrastructure     making role in service planning
Practice Level                                                                            Practice Level
• Ensure effective and accessible service     Branch Functions                            • Increased use of evidence-based
  delivery                                    • Technical Assistance for grant              practice
• Ensure sufficient and trained workforce       preparation                               • Increased workforce training
• Promote culturally & linguistically         • Oversee all implementation                • Practice reflects the cultural and
  responsive service practices                  requirements of grants, cooperative         linguistic characteristics of the
                                                agreements and contracts                    population being served
System Level
• Raise awareness about child & youth         Extensive Partner Network                   System Level
  mental health issues                        • Communications                            • Increased sustainability of grantees
• Ensure collaborations to integrate mental   • Technical Assistance                      • Increased collaboration across federal
  health as a component in overall health     • Research / Evaluation                       agencies
• Ensure access to resources to address       • Agreements with other federal agencies    • Sustained or increased funding
  child and family mental health issues                                                     available for the support of programs
   Family driven means…

 Families have a primary decision
  making role in the care of their own
  children as well as the policies and
  procedures governing care for all
  children in their community, state,
  tribe, territory and nation.
Family driven means that families
        take the lead in…
 Choosing supports, services, and
 Setting goals;
 Designing and implementing programs;
 Monitoring outcomes; and
 Determining the effectiveness of all
  efforts to promote the mental health and
  well being of children and youth.
    Youth Guided means that youth
          take the lead in…

    Educating all professionals and
     adults who work with young
     people on the importance of
     engaging and empowering
Youth Involvement in Systems of Care

     A starting point for
      understanding youth
      involvement and
      engagement in order to
      develop and fully integrate a
      youth-directed movement
      within local systems of care.

    Cultural & Linguistic Competence

    Reduce disparities and enhance cultural and linguistic
     competence among policy-makers, administrators and
     service providers.

         •   Enhance organizational capacity
             for cultural and linguistic competence.

         •   Increase awareness and knowledge
             of factors that contribute to disparities.

         •   Develop specific approaches
             that contribute to the goal of eliminating disparities.
                    Clinical Excellence

   Promote the active training of providers on
    state-of-the art, culturally and linguistically
    competent clinical practice.
                         Evidence Based Practice
   Promote the local and national evaluation of research data to identify
    evidence-based practices.Develop a research agenda to enhance the
    understanding of how to develop and provide effective, efficient and
    coordinated services within Systems of Care.

       •   Priority list of research areas to
           guide the national evaluation.

       •   Searchable electronic
           knowledge management system.

       •   Infrastructure for supporting
           activities of a National
           Evaluation Data Users Group.

       •   CQI report card.
                           # of Children Served (total)

                           # of Children Served (annual)
70                         # of New Enrollees (annual)                                                                $112
                           Congressional Allocations (in millions)
                           Fiscal Year Expenditure per Child











            3      4       5      6       7       8       9       0       1       2       3       4       5       6
          99     99      99     99      99      99      99      00      00      00      00      00      00      00
      F Y1    FY1    F Y1    FY1    F Y1    F Y1    F Y1    F Y2    F Y2    F Y2    F Y2    F Y2    F Y2    F Y2

                     Through Fiscal Year (FY) 2005: 73,383 children served
                        Average # of children served per year = 11,278
             Average Federal expenditure per child across program years = $13,039
           or ~ $150/week in services per child (estimated length of stay ~ 17 months)
                       Cost Savings from Reduction in Inpatient Hospitalization:
                                        Intake to 12 Months*
                                                      3.6                                      Intake           12 months

                                                                        Average per child cost savings =
Mean # of days

                 2.0                                                                          1.8


                                                                       (n =3,563)

                       *Average  difference in inpatient hospitalization days multiplied by the national daily cost estimate.
                       The Agency for Healthcare Research and Quality (AHRQ) estimated the national average daily
                       cost of inpatient hospital care in 2002 was $1,501 per day (AHRQ, 2004).
                                    Cost Savings from Reduction in Arrests: Intake to 12 Months*
Mean # of arrests in past 6 mo.                                                                             Intake          12 months

                                                                                  Average per child cost savings =
                                  0.5                                                         $784.16


                                                                                     (n =3,563)

                                        *Average  difference in number of arrests multiplied by the national cost estimate. The Bureau of
                                        Justice Statistics estimated the average cost per juvenile arrest was $4,149 in 2000 (CASA, 2004).
Adjusted and Unadjusted Between-Site Differences
      in Expenditures: Entry to 12 Months*
                  Core MHS                                                                 $1579

            Juvenile Justice $-687

               Child Welfare                   $-60

          Special Education                                  $294

              Inpatient MHS             $-258

    All Sectors (Unadjusted)

All Sectors (Propensity Score)              $-102

                           $-1000      $-500          $0      $500       $1000       $1500          $2000
                                                Average Costs Per Participant
     Funded community spent more on mental health and special education per child.
     Comparison community spent more on juvenile justice, child welfare and inpatient per child.
     After statistical adjustment, overall costs across all sectors essentially the same.
Reduction of Juvenile Justice Involvement

 Initial involvement and recidivism rates for
  serious crimes decreased significantly in
  funded community.

 Recidivism rates for serious crimes increased
  in comparison community
Changes in Juvenile Justice Involvement
           Rates over Time
                                       Intake       18 months

                 70%        66.8%


                 50%                  46.5%
                 20%                                                   13.7%
                             Jefferson                     Montgomery
  The proportion of youth charged with crimes decreased significantly* during the first 18 months of
  services in the Jefferson county system of care. Conversely, the rates of juvenile justice
  involvement among youth in Montgomery county increased.
    Continuous Quality Improvement (2)

   It is imperative that we apply a
    CQI mindset to every initiative,
    program, or practice approach we
    take. We must constantly be
    asking ourselves “How can we
    make what we are doing better?”

   CQI - requires that you raise the
    bar even higher, and ask yourself
    how you could make it even
    Specific continuous quality improvement efforts
   Startup Teams for new sites

   Expanding populations of concern for system of care communities

   Expanding target population to include those youth who have, or who are
    at risk of having a serious emotional or behavioral disorder

   Advancing the concepts of Family Involvement/ Family –Driven &
    Youth Guided within the systems of care.

   Reducing disparities and enhancing cultural and linguistic competence
    within the Comprehensive Children’s Mental Health program.

   Developing a research agenda to enhance the understanding of how to
    develop and provide effective, efficient and coordinated services within
    systems of care.
From Ordinary…
To Extraordinary…
   Remember ~
    youth and families are at the core
    of all that we do

   Rededicate ~
    to system of care values and principles

   Rejoice ~
    Our accomplishments, our spirit, and
    our resiliency

             Oh yeah, have
              some fun… but
              don’t play with
Remember, Rededicate, Rejoice & Transform

                             Turn a
                             bad hair
                             day into
                             a new

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