Begin with
the end in
mind…
Accessing effective
psychosocial
treatment options
Nadia Sexton, Ph.D.
Casey Family Programs
Senior Fellow to ACYF & CMS
Expectation from the top leadership:
Make the Case
Enlist and align leadership with common language and
knowledge
Complex Trauma:
• Complex Trauma in Children and Adolescents: White Paper from the National
Child Traumatic Stress Network Complex Trauma Task Force. Substance Abuse
and Mental Health Services Administration (SAMHSA, USDHHS).
Adverse Childhood Events:
• www.acestudy.org
Trauma guided child welfare system: Building Well-Being
Through Trauma-Informed Child Welfare Systems
:
Policy Framework
Define:
• Well Being
• Change Management
• Case Practice and Interventions
• Fundamentals
• Quality Assurance/Performance Improvement
• Outcomes
• Engagement and Learning
• Practice Parameters
• AACAP
New heroes may be found in the public health, early childhood,
community affairs, and public works agencies in your state
Capacity of the Workforce
Define for the Child Welfare and Psychosocial/Social
Services Provider Community
•
•
•
•
Case Practice and Interventions
Fundamentals (screening/assessment, when to dx, consent protocols)
Quality Assurance/Performance Improvement
Outcomes
Check out:
http://www.casey.org/Resources/Publications/pdf/Mental
HealthPractices.pdf
Low Hanging and High Yielding Fruit
•
•
•
•
Uniform Assessment
Definition of youth and family engagement practices
Partnership with provider community
Partnership with your state’s higher education community
Financing
A simple start
Your state spends
money on children in
programs:
• Who are they and
what are they getting?
• What is the
funding/contracting
model?
Medicaid Expenditures for Children in Child Welfare
On average, states spend three times more for this population than for nondisabled
children in Medicaid — approximately $4,336 for children in child welfare versus $1,315
for the general child population without disabilities.
R. Geen, A. Sommers, and M. Cohen. Medicaid Spending on Foster Children. The Urban Institute, Brief No.
2, August 2005. Available at: http://www.urban.org/UploadedPDF/311221_medicaid_spending.pdf.
In California, for example, Medicaid-eligible children in foster care accounted for 53
percent of all psychological visits, 47 percent of psychiatry visits, 43 percent of the public
hospital inpatient hospitalizations, and 27 percent of all psychiatric inpatient
hospitalizations among the program’s entire child population.
Excerpt from Testimony from John Landsverk, PhD, at Testimony to the Little Hoover Commission
Children’s Mental Health in Child Welfare and Juvenile Justice, a Public Hearing on Children’s Mental Health
Policy on October 26, 2000, in Sacramento, California.
A Pennsylvania study found that Medicaid mental health-related expenditures for
children in foster care are nearly 12 times greater than costs for non-foster children. This
study found that utilization rates, expenditures, and prevalence of psychiatric conditions
for children in foster care were comparable to those of children with disabilities (i.e.,
children receiving Supplemental Security Income).
J. S. Harman, G. E. Childs, and K. J. Kelleher. “Mental Health Care Utilization and Expenditures by Children
in Foster Care.” Archives of Pediatrics &
Adolescent Medicine, 2000,154:1114-1117.
From: Allen, Kamala (2008) Issue Brief: Medicaid Managed Care for Children in Child
Welfare; Center for Health Care Strategies, Inc.
Paid Claims 2010 Foster Youth by Service
source: msis.ms.hhs.gov
$4,500,000,000.00
$4,000,000,000.00
$3,500,000,000.00
$3,000,000,000.00
$2,500,000,000.00
Sum of Medicaid/CHIP
Sum of EPSDT
$2,000,000,000.00
Sum of Home/Community
Waivers
$1,500,000,000.00
Sum of FQHC
Sum of In Pt MH <21
$1,000,000,000.00
$500,000,000.00
$0.00
Financing
EPSDT
Consider:
•
•
•
•
•
Early
Periodic
Screening
Diagnostic
Treatment
Screening and Assessment is an entitlement to
youth in the public system.
Medicaid expenditures on psychotropic medications for
children in the child welfare system. Raghavan et al (2012)
http://www.ncbi.nlm.nih.gov/pubmed/22537361
RESULTS:
Children surveyed in NSCAW had over thrice the odds of any psychotropic drug use
than the comparison sample.
Each maltreated child increased Medicaid
expenditures by between $237 and $840 per year, relative to
comparison children also receiving medications.
On average, an African American child in NSCAW received $399 less
expenditure than a white child…………..Children scoring in the clinical range of
the Child Behavior Checklist received, on average, $853 increased expenditure
on psychotropic drugs.
CONCLUSION:
Each child with child welfare involvement is likely to incur upwards
of $1482 in psychotropic medication expenditures throughout his
or her enrollment in Medicaid.
Financing
What is child welfare spending on now?
How about buying outcomes instead of services?
Financing
The goal is to spend on trauma informed
treatments
• Trauma-Informed Treatments place a
greater focus on:
• Safety
• Adult Support
• Resilience and Protective Factors
• Trauma-Informed Treatments focus less on
medications and are less stigmatizing
Making Choices: Start Here
Making Choices: Start Here
Interventions Addressing Child Exposure to
Trauma: Child Maltreatment (Part 1)
Have a look:
Part 1 (in draft) focuses on the comparative effectiveness of interventions that
address child exposure to familial trauma in the form of maltreatment, including
post-traumatic stress disorder as an outcome of interest.
Research protocol:
www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-andreports/?productid=846&pageaction=displayproduct
subscribe:!: http://effectivehealthcare.ahrq.gov/index.cfm/join-the-email-list1/
Examples for Making Choices
Population guided:
• Disruptive Behavior
http://store.samhsa.gov/product/Interve
ntions-for-Disruptive-BehaviorDisorders-Evidence-Based-PracticesEBP-KIT/SMA11-4634CD-DVD
Examples for Making Choices
Provider Network Guided
Examine the data and lessons learned
Alternatives to Psychiatric Residential Treatment
Facilities Demonstration (PRTF)
There is a positive effect of either maintaining or
improving children’s functional outcome in juvenile
justice, school functioning, substance abuse, and
involvement with child protective services.”
Examples for Making Choices
Building Capacity:
The Effective Providers for Child Victims of
Violence Program
Examples for Making Choices
Goal: Increase mental health professionals’ capacity to provide effective
treatments to children victimized by violence.
Objective: Develop a national training program to:
 mobilize mental health professionals and allied professionals to
embrace evidence-based trauma assessment tools and treatment
models
 increase the number of mental health professionals informed about
and prepared to make decisions about adopting family-oriented,
culturally sensitive, evidence-based treatments for children who are
victims of violence
Examples for Making Choices
Core Elements for Effective Treatment
Adopt empirically-supported assessment tools
Be culturally competent
Adopt evidence-based treatment models
Involve families
Collaborate with other professionals and system of care
Examples for Making Choices
Curriculum
Basic overview of the best available science about:
Impact of exposure to violence and trauma on children
Six Trauma-Focused Assessment Tools
Five Trauma-Focused Evidence-Based Treatments
Role of Culture and Diversity in Victimization and Treatment
Family-Centered, Collaborative Treatment Approach
Clinician’s Self-Care
www.apa.org/pi/prevent-violence/programs/child-victims.aspx
www.Facebook.com/APAEPprogram
Places to go…
The California Evidence-Based Clearinghouse for Child Welfare
Begin with the end in
mind.
Know your own
landscape.
Have your data ready:
youth, services, $
Find, adopt, charm,
and engage partners.
Choose and step and
make it.