Clinical Direction of The Wyoming Sage System of Care.

Clinical Direction for the Wyoming SAGE System of Care

It’s estimated that 4.5 to 6.3 million children and youth in the U.S. suffer from a serious emotional disturbance and approximately 65% to 80% of these children and youth do not receive the specialty mental health services and supports they need. President Bush’s National Commission on Mental Health studied and made recommendations for improving America’s mental health service delivery system that resulted in a blueprint for transformation. The President’s New Freedom Commission on Mental Health is described in Achieving the Promise: Transforming Mental Health Care in America. The report is available at: http://www.mentalhealthcommission.gov/reports/reports.htm

The Substance Abuse and Mental Health Services Administration (SAMSHA), Center for Mental Health Services (CMHS), has been charged with the responsibility to implement the goals and recommendations of the New Freedom Commission. The Child Mental Health Initiative (CMHI) represents the largest and most targeted federal effort to transform children’s mental health services.

The Wyoming SAGE System of Care is funded by federal Child Mental Health Initiative (CMHI) funds from SAMSHA/CMHS. The CMHI funds are known federally as the “Comprehensive Community Mental Health for Children and Their Families Program.” Over the years many people have come to refer to these initiatives as children’s mental health “system of care grants.”

This movement towards organized “systems of care” began in the early 1980’s with the Child and Adolescent Service System Program (CASSP). CASSP provided funds and technical assistance to all fifty states and several U.S. territories. CASSP recognized that children with serious disorders are often involved in multiple public systems (education, child welfare, juvenile justice and mental health). A core set of CASSP values and principles evolved from this work. These core values and principles are known today as the “System of Care Values and Principles”.

The CMHI has certain goals, requirements and activities designed to assist and support state and local child-serving entities in building a solid foundation for delivering and sustaining effective systems of care for children with serious emotional disturbances and their families. These activities are priorities for the SAGE System of Care and the pilot regions and communities funded through the SAGE System of Care with the CMHI, matching state dollars and in-kind contributions.

Program Goals

Expand community capacity to serve children and adolescents with serious emotional disturbances and their families;
Provide a broad array of effective services, treatments and supports;
Create a case management team with an individualized service plan for each child;
Incorporate culturally and linguistically competent practices for serving all children, youth and their families. Further, to eliminate disparities related to race, ethnicity, or geographic location; and,
Promote full participation of families and youth in service planning and in the development of local services and supports.

Desired Clinical and System Outcomes

System level infrastructure will be created and sustained.
Over 75% of the referrals will come from non-mental health resources.
Cross-agency individualized care planning for children will increase over time.
Behavioral and emotional problems will improve.
Law enforcement contacts will be reduced.
School attendance and performance will improve.
Stable living arrangements will increase.
Clinical and functional improvements will be achieved for children and youth.
Children with co-occurring mental and substance abuse disorders will experience significant improvements in mental health functioning.
Children will experience reductions in the use of inpatient care whole being served in the community through systems of care.

Certain core mental health and support services are required and must be provided by awardees of SAGE System of Care funds. Other additional services are optional. Some non-mental health services need to be included in the individualized plan of care, even though funds from the CMHI cannot be used to purchase them.

Required Mental Health and Support Services

Diagnostic and evaluation services;
Care management;
Development of an individualized service plan
Outpatient services provided in a clinic, office, school, or other appropriate location, including individual, group and family counseling services, professional consultation, and review and management of medication;
Emergency services, available 24 hours a day, 7 days a week, including crisis outreach and crisis intervention;
Intensive home-based services for children and their families when the child is at imminent risk of out-of-home placement, or upon return from out-of-home placement;
Intensive day treatment services;
Respite care;
Therapeutic foster care;
Therapeutic group home services caring for not more than 10 children(ie. Services in therapeutic foster family homes or individual therapeutic residential homes); and
Assistance in making the transition from the services received as a child and youth to the services received as an adult.

Note: The required services listed above should be integrated, when appropriate, with established alternative or traditional healing practices of racial or ethnic minority groups represented in the community, especially if there are indications that such integration will reduce racial or ethnic disparities in mental health care.

Section 562(g) of the Public Health Service Act allows for a waiver of one or more of the above service requirements for applicants who are and Indian Tribal or tribal organization, if SAMSHA/CMHS staff determines, after peer review, that the system of care is family-focused, culturally competent, and uses the least restrictive environment that is clinically appropriate.

Optional Services

Screening assessments to determine whether a child is eligible for systems-of-care services;
Training in all aspects of system of care development and implementation, including evidence-based interventions;
Therapeutic recreational activities; and
Mental health services (other than residential or inpatient facilities with ten or more beds) that are determined by the individualized care team to be necessary and appropriate and to meet a critical need of the child or the child’s family related to the child’s serious emotional disturbance.

Non-mental Health Services

Funds from this program cannot be used to finance non-mental health services, however, non-mental health services play an integral part in the individualized service plan for each child and their family. The system of care must facilitate the provisions of such services through coordination, memoranda of understanding, and agreement/commitment with relevant agencies and providers. These services should be supplied by the participating agencies in the system of care and include, but are not limited to:

Educational services, especially for children who need to be placed in special education programs;
Health services, especially for children with co-occurring chronic illnesses;
Substance abuse treatment and prevention services, especially for children with co-occurring substance abuse problems;
Vocational counseling and rehabilitation, and transition services offered under IDEA, for those children 14 years or older who require them; and
Protection and advocacy, including informational materials for children with a serious emotional disturbance and their families in the foster care system, who need to know about their rights as consumers of services, and assistance for any child with a serious emotional disturbance and the child’s family about appropriate services available to them.

Co-occurring disorders

Serious Emotional Disturbance and Substance Use
A relatively high percentage of adolescents with a serious emotional disturbance are expected to have a co-occurring substance use disorder. In such cases, treatment for the substance use disorder should be included in the individualized care plan. For those children with a serious emotional disturbance who are at risk for, but have not yet developed, a co-occurring substance use disorder, prevention activities for substance abuse may be included in the individualized care plan.

Serious Emotional Disturbance with Developmental Disabilities and/or Chronic Illnesses

Children with a serious emotional disturbance often have co-occurring illnesses and/or developmental disabilities. Therefore, collaboration with the primary care and DD service systems, including collaboration with family physicians, pediatricians, and public health nurses, among others, must be developed within the system of care. Such collaboration must include, at a minimum, systematic procedures that primary care providers can follow to refer children and their families to the system of care. It also must include procedures for including primary care providers in individualized service planning team and in the wraparound process.

Key Activities and Concepts of Service Provision

The provision of systems-of-care services for children with a serious emotional disturbance and their families emphasize:

Delivery of effective clinical interventions, which as research has demonstrated, produce positive child and family outcomes;
Provision of care management services for each child and the child’s family; and
Development of an individualized care plan for each child and the child’s family.
Presence of a strong family and youth voice in all aspects of governance of the system of care, service delivery and evaluation.
Promotion of cultural and linguistic competence and responsiveness by individual service providers and agencies to ensure and support the well-being of children and their families.

Delivery of Clinical Interventions

Clinical interventions include diagnostic assessments, treatment planning and service delivery provided to individuals and families. Clinical interventions should be adapted for racial and ethnic minority populations, and strategies related to clinical training and the use of evidence based treatments must be incorporated.

Delivery of Care Management Services

Care management, or care coordination services, tailored to the needs of individual children are required for all children and adolescents who are offered access to the system of care under this program. Care management represents the procedures that a trained service provider uses to access and coordinate services for a child with a serious emotional disturbance and the child’s family.

Development of an Individualized Care Plan

Each child or adolescent served within the system of care funded under this program must have an individualized care plan developed by an interagency team, which includes the child’s parent or legally responsible adult and, unless clinically inappropriate, the child or youth. The individualized care plan refers to the procedures and activities that are appropriately scheduled and used to deliver services, treatments, and supports to a child and the child’s family. These procedures and activities must fit the unique needs of the child and the child’s family and build on child and family strengths. Thr group that assists the care manager, family member, and child to implement the individualized care plan is the individualized care team. This team is comprised of representatives from child-serving agencies that provide services to the child and family, as well as other significant individuals in the community who relate closely to the child and family, such as a minister, friend, or community leader.

Family-Driven

The system of care must respect the goals and objectives of its’ ultimate consumers: the child or youth with a serious emotional disturbance and his/her family. Family-driven means that families have a decision making role in the care of their own children as well as the policies and procedures governing care for all children in the community, state, and nation. This includes choosing supports, services, and provider; setting goals; designing and implementing programs; monitoring outcomes; and determining effectiveness for all efforts to promote the mental health of children and youth.

Youth-Guided

Youth are playing an increasingly important role in planning their own treatment, and for seeking ways to improve the service deliver system. Youth involvement in these activities must be encouraged and supported.

Cultural and Linguistic Competence

Cultural and linguistic competence is defined as an integrated pattern of human behavior that includes thoughts, communications, languages, practices, beliefs, values, customs, courtesies, rituals, manners of interacting, roles, relationships and expected behaviors of a racial, ethnic, religious or social group; the ability to transmit the above to succeeding generations; is dynamic in nature.

Challenges and Opportunities

All of the areas listed above play a major role in defining and implementing and sustaining an efficient and effective system of care for Wyoming children and their families. The SAGE System of Care is in its first year of financing pilot sites (communities and regions) to begin this challenging and important task. There are already many components of a system of care in place that need wove together in a more comprehensive and easily accessed (“no wrong door”) system. Major hurdles are present, however, they are identifiable and the solutions are manageable when utilizing the lens of the system of care values and principles. Communities are motivated to seek and employ the tools they need to establish effective and efficient systems of care for their children, families, and other stakeholders. The time is right.

In addition to the system work that has been mentioned, a very important component of the development of an efficient and effective system of care for children with serious emotional disturbance and their families must include clinical practices that are “evidenced based.”

“Evidence based practice is the integration of best research evidence with clinical expertise and patient values.” Institute of Medicine

It is important that the state child-serving agencies, communities and parents are all familiar with the concept of evidenced based practices. While researching, studying and selecting evidenced based practices for the system of care it’s important to consider the rural/frontier nature of our state as well as the availability of professionals who may be required to maintain fidelity to the evidenced based models we’re interested in using. Some evidence based practices are currently being utilized in Wyoming and the national evaluation required by our system of care work can tell us quite a bit about the efficacy of these practices currently in place.

The national evaluation data can also tell Wyoming stakeholders, as well as federal funding sources like SAMSHA, what works well for children and families who live in rural/frontier states. Identifying opportunities for system improvement through current effective practices can be considered “practice based evidence.” By recognizing and understanding the importance and value of the messages from Wyoming’s children and families regarding their experiences utilizing system of care services, and the experiences of the practitioners who provide these services and supports, we can learn a great deal about practice based evidence within our unique system of care.

Please stop back again for additional postings on clinical issues related to the SAGE System of Care and national system of care movement information.