Fostering Systems of Care Initiative (SOCI) Program: Cross Sectional Descriptive Study

Fostering Systems of Care Initiative (SOCI) Program: Cross Sectional Descriptive Study (Phase II)

Investigators:Lori Bilello, PhD,MBA,MHS; William Livingood, PhD; Cecila Freer, MPA; Maria Bautista, MD, MPH

Abstract

The system of care (SOC) program theory (Stroul & Friedman, 1986) asserts that to serve children and youth with emotional and behavioral disorders, service delivery systems need to offer a range of diverse, accessible, community-based services that arefocused on children’s individual needs, where families are active partners in their child’s treatment plan and delivery, and the services are provided in a culturally competent manner. The goal of the SOC program is to provide wraparound mental health services to children in the least restrictive setting. A critical component of the SOC program is the inter-agency collaboration and partnership within the community (e.g. education, juvenile justice, mental health, and child welfare). This inter-agency partnership advocated by the SOC can help facilitate the coordination and provision of the variety of services that children and youth with emotional and behavioral disorders will need.

This is an evaluation, which is in compliance with the national evaluation requirements to collect demographic and diagnostic data for all children and youth served by the cooperative agreement.

Background

In 2010, the Jacksonville System of Care Initiative (SOCI) was awarded a cooperative agreement by the Substance Abuse and Mental Health Services Administration (SAMHSA) to benefitthe system for mental health services within Duval County, Florida. Subsequently, the University of Florida, College of Medicine – Jacksonville, Center for Health Equity and Quality Research (UF CHEQR) was awarded a sub-contract through the City of Jacksonville and Managed Access to Child Health (MATCH, Inc.) to evaluate the Initiative. This evaluation is required by the SAMHSA Comprehensive Community Mental Health Services for Children and Families Initiative (CMHS) through the prescribed National Evaluation and National Outcome Measures.

The National Evaluation will assess the number of children served, child, youth and family characteristics, child, youth and family outcomes, and system characteristics. These areas will be assessed using several methodological approaches over the 6-year period of the cooperative agreement. In this application we focus onthe Cross Sectional Descriptive Study. UF CHEQR is responsible for submitting demographic and diagnostic criteria to SAMHSA as part of the Cross Sectional Descriptive Study. This information is collected using the Enrollment Demographic Information Form (EDIF).

In addition to the national evaluation, the grant also requires the incorporation of another federal requirement. This component is referred to as the CMHS Transformation Accountability (TRAC) National Outcome Measures (NOMs). The Government Performance and Results Act (GPRA), established in 1993, was intended to increase program effectiveness and public accountability by promoting a new focus on results, service quality, and customer satisfaction. In order to better meet these GPRA expectations, SAMHSA has established TRACNOMsto promote the use of consistent measures across its programs. Therefore, UF CHEQR is responsible for using the TRAC NOMs form as well to collect federally required data.

The TRAC NOMs are comprised of ten domains that embody meaningful, real life outcomes for people who are striving to attain and sustain recovery; build resilience; and work, learn, live, and participate fully in their communities (Center for Mental Health Services, 2011). Data from the TRAC NOMs Study will be used by the federal government to evaluate the effectiveness of the various CMHS-funded programs, including funded systems of care.

Specific Aims

The main objective is to monitor the SOC via results of the national evaluation requirements. Another objective is to provide services to children in the least restrictive setting.

The national evaluation requirement is modeled to answer the following questions (Manteuffel et al., 2010, p 5):

• To what extent do systems of care develop and improve over time?
• What services do children and families receive, what service utilization patterns do they experience, and what are the costs of those services?
• What are the characteristics of the children and families served by systems of care?
• To what extent do client outcomes improve over time?
• To what extent do children and families experience service delivery in keeping with the system-of-care program model?
• To what extent can improvements in children’s behavior and functioning be associated with a system-of-care approach?

The flow chart on the next page outlines two processes for data collection UF CHEQR staff will be data collectors for both the homeless and early learner target populations. JSOCI program staff will be data collectors for the remaining populations and will share data collection responsibilities with CHEQR staff for the early learner population.

PI Version date: 12/19/2014

PI Version date: 12/19/2014

The SOCI program

The following section is provided as background and describes the System of Care Initiative (SOCI) program. Research activities will be described in the Program Monitoring/Data Collection Plan section.

Recruitment, Screening, and Referral Process

The population of focus for the System of Care Initiative (SOCI) is children and youth between the ages of 1 day – 21 yearsand their families. In order to be eligible for services through this initiative, families and their child(ren) should be (a) a member of one of the SOCI’s populations of focus (homeless, foster care(including at risk for child welfare involvement), juvenile justice, or receiving subsidized early learning services, (b) screened using an evidence-based assessment tool, and assessed to have or be at risk for severe emotional and behavioral disorders, (c) interested in receiving therapeutic services, and (d) intending to reside in Jacksonville. The four populations of focus are defined as follows. A child who is homeless means that the child is sleeping in a place not meant for human habitation or is living in a homeless shelter (HUD Definition). The foster care population is defined by children who are currently part of the child welfare system in Duval County. Within this foster care group the at risk population is defined as children or youth who have been referred or have self-referred for wraparound services or other mental health services due to issues related to behavioral or mental health issues which may have resulted or may result in future out-of-home placement with Department of Children and Families. Children and youth in the juvenile justice population are defined by contact with the juvenile justice system such as probation, and are not in detention. The early learner population is defined as children ages 0-5 who are receiving subsidized early learning services, such as Head Start or Early Head Start.

Families and children may receive either high fidelity wraparound, targeted case management services, or other mental health services through this initiative. In order to be eligible for high fidelity wraparound services through this initiative, families and their child(ren) should fulfill the following criteria:

(1)Residency: The parents, guardians or primary caregiver of eligible children and youth will live in Duval County.

(2)Age: Eligible youth will be from 1 daythrough 21 years of age.

(3)Severe Emotional Disturbance: Eligible youth will be determined to have a severe emotional disturbance. The following definition will be used for Severe Emotional Disturbance. The disability must show evidence of all below:

1. The disability must have persisted for six months and expected to persist for a year or longer.
2. Condition of severe emotional disturbance as defined by: A mental or emotional disturbance as listed in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR).
3. Functional Symptoms and Impairments: the youth must exhibit either (i) or (ii) below:
4. Symptoms: the individual must have one of the following:
5. Serious mental illness (e.g.,attention deficit hyperactivity disorder, major depressive disorder, bipolar disorder)
6. Danger to self, others and property as a result of emotional disturbance. For example, the individual is self-destructive (e.g., runaway, at risk for suicide)
7. Functional Impairment in at least two of the following capacities:
8. Functioning in Self-Care: Impaired ability to take care of personal grooming, hygiene, clothes and meeting of nutritional needs.
9. Functioning in the Community: Impairment in community function is manifested by consistent lack of age appropriate behavioral controls, and/or decision-making. For example, judgment and value systems may result in potential involvement or actual involvement with the juvenile justice system.
10. Functioning in Social Relationships: Impairment in social relationships manifested by consistent inability to develop and maintain positive relationship with peers and adults.
11. Functioning in the Family: Impairment in family function manifested by disruptive behavior by repeated and/or unprovoked violence to siblings and/or parents, disregard for safety and welfare of self and others (e.g., chronic destructiveness).
12. Functioning at School/Work: Impairment in functioning at school is manifested by the inability to pursue educational goals in a normal time frame (e.g., consistent with failing grades, repeated truancy, expulsion).
13. The individual must be receiving services from, or at risk of receiving services from any of the following service systems:
14. Subsidized Child Care Services
15. Juvenile Justice Services
16. Homeless Services
17. Child Welfare Services
18. Youth must have a Global Assessment of Functioning (GAF) of 60 or below.

(4)At Risk of Placement: Some eligible youth may be in an out-of-home placement or at risk of one.

(5)Multiple Hospitalizations due to the Florida Baker Act Law: The state’s law allows for the involuntary hospitalization of individuals who are believed to be mentally ill. As a result the individual may refuse examination and without treatment may refuse to care for him/herself or are in danger of harming themselves or others. Some youth who have had multiple hospitalizations in the past due to this law are eligible for SOCI enrollment.

In order to receive targeted case managementor other mental health services through this initiative, families and children must meet all the criteria above except for item 3d. Those children eligible for targeted case management may not have received services in the past from any service system listed in the item.

Prior to enrollment in the SOCI, community-based service providers associated with each population of focus will screen children/youth for emotional and behavioral disorders as described below.

Homeless.Children, youth and their families recruited and enrolled in the SOCI Homeless Initiative include sheltered homeless families with children ages 1 dayto 21years who live in the Jacksonville shelters that Medical Home for Homeless Children Project (MHHCP) serves. This includes: The Sulzbacher Center, Hubbard House, Community Connections, The Davis Center, Family Promise of Jacksonville, Trinity Rescue Mission, Salvation Army, City Rescue Mission, Gateway Residential Treatment Center, and The Inn Ministry.

MHHCP will screen each child/youth for emotional and behavioral disorders using the Strengths & Difficulties Questionniare following receipt of parent consent/youth assent. The screening will take place shortly after intake. Any children/youth who screen positive for any emotional and behavioral disorder will be referred to Daniel Memorial,Right Path, or other service providers to receive further assessment and receive either high fidelity wraparound or targeted case management (TCM) services.

Upon receipt of referral from MHHCP, an intake coordinator from Daniel Memorial or other service providerswill schedule the child/youth and family’s first appointment and assign them to a wraparound coordinator, therapist, or targeted case manager (as appropriate based on the eligibility criteria listed above) who will be working with the family. Based on an initial screening, the clinical director at Daniel or other service providerswill confirm and/or provide a mental health diagnosis, which will allow the child/youth and family to be enrolled in the SOCI.

Foster Care.The population of focus will be youth and their families recruited and enrolled in the System of Care Initiative (SOCI) who are a part of the Foster Care Program. These will be children/youth, ages 1 dayto 21 yearswho have received shelter orders from Department of Children and Families and referred by Family Support Services (FSS) to the Partnership for Child Health Nurse Care Coordinator (NCC).

The Partnership for Child Health NCC will identify children/youth who have a severe emotional disorder (SED) through several agency referral processes; the collection of the Comprehensive Behavioral Health Assessment (CBHA), Ages and Stages Questionaire: Social and Emotional Wellness (ASQ:SE) and Care and Assessment Plan (CAP); Primary Care Providers, Immunization, Dental, Hospitalization and Psychiatry records; an initial 72 hour In Care Medical Screening and a 30 day Medical Comprehensive Assessment.

The initial referrals to high fidelity wraparoundinvolved with Foster Care are separate from the SOCI since these referrals may include primary care, dental and other services providers outside of the SOCI. These services remain separate from the SOCI for the first 30 days of being in the Foster Care system but can potentially become apart of the SOCI if the child is deemed eligible for the SOCI Wraparound services. During this timeperiod, prior to the 30 day comprehensive physical, FSS requests that a Comprehensive Behavioral Health Assessment (CBHA) be completed on each child by one of their contracted entities. During the time prior to the 30 day comprehensive physical, FSS requests that a Comprehensive Behavioral Health Assessment (CBHA) be completed on each child by one of their contracted entities.

At the approximate 30 day mark, FSS receives the completed CBHAs from the contracted entity and evaluates them for eligibility to be enrolled inthe SOCI. A SOCI staff member or designee will determine if the child is eligible for High Fidelity Wraparound for children ages 6-17 and a case plan will be developed by the high fidelity wraparound team. Families of children who have experienced out-of-home placement or are at risk of out-of-home placement may self-refer for wraparound services. Once JSOCI is contacted by the family, mental health screening will take place, and a wraparound coordinator will be assigned. At-risk youth who are not involved in multiple agencies, yet are seeking services that they are having difficulty accessing either on their own or through one agency, and are at least in one system, will be referred for targeted case management or other mental health services.Nurse care coordinators will follow up on mental health referrals from CBHAs for children ages 0-5 and will make appropriate referrals to community-based early childhood mental health service providers, such as Children’s Home Society and Child Guidance Center.

Juvenile Justice. The juvenile justice population of focus will be referred and recruited into the Descriptive Study from community-based mental health services agencies such as the Delores Barr Weaver Policy Center (DBWPC) and Gateway Community Services.

The DBWPC provides mental health services to youth in the juvenile justice system. JSOCI program staff (i.e., therapists from the Delores Barr Weaver Policy Center) will screen and provide mental health services (e.g., individual therapy) to youth who may meet JSOCI eligibility criteriaand who are either under probation supervision to DJJ, currently committed to a juvenile residential program, have been released, or participating in a juvenile diversion program. If the youth and family meet eligibility criteria, they will be assigned a therapist and services will be initiated. The therapist will initiate the consent process for the Descriptive study.

Gateway Community Services care coordinators will screen juvenile offenders at the Juvenile Assessment Center for mental health and substance abuse risk factors. Based on the result of the screen the care coordinators will refer youth to appropriate mental health and substance abuse services. These care coordinators will refer youth who meet Jacksonville System of Care Initiative eligibility criteria for wraparound care coordination from JSOCI program staff.

Because youth may be entering detention or already in detention prior to service initiation, special attention will be given to the consenting process, as outlined in ‘Special Consent Procedures for Youth and Caregivers in Detention’, shown below.

Early learners. The early learner population will be referred into the JSOCI by an early learner screenerwho will refer screened children to JSOCI service providers.

Children receiving mental health services from Daniel Memorial service providers who have been trained in the SOCI principles will be eligible for the studies. These children may be referred from the above detailed channels or may be referred to Daniel by other community agencies.