Division of Behavioral Health Alaska Mental Health Trust
Division of Behavioral Health Alaska Mental Health Trust Authority Caring for Alaska’s Children and Youth in Out-of-Home Behavioral Health Care Tuesday, March 19, 2019
Agend a 8: 30 – 8: 45 – 9: 00 objectives 9: 00 – 9: 20 Williams 9: 20 – 10: 00 – 10: 15 10: 30 – 12: 15 – 1: 00 – 2: 00 Acute Care 2: 00 – 2: 15 – 3: 15 Tx 3: 15 – 4: 30 Registration Welcome; agenda; Keynote: Steve Settings and costs Break Overview; TFC Lunch Residential BRS; Break Residential Psychiatric Group discussions; 2
About 20% of the audience is on the phone In-person Participants When asking a question or making a comment: Introduce yourself (name and organization) and use the microphone. Teleconference Participants Put call on mute and do not place the call on hold. All Silence cell phones. 3
Today’s Objective s 1. Learn about the children living in out-of-home behavioral health care. 2. Understand how the implementation of the Bring the Kids Home initiative shapes our current services and how implementation of the 1115 waiver will change services. 3. Identify ways to improve the current system of care to achieve better outcomes for children in out-of-home behavioral health care. 4
Bring the Kids Home Initiative: A brief history Source: Alaska Department of Health & Social Services, Division of Behavioral Health 5
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Bring the Kids Home Initiative: Primary Goals 1. Significantly reduce the numbers of children and youth in out-of-state care and ensure future use of out-of-state facilities is minimum. 2. Build the capacity within Alaska to serve children with all intensities of need. 3. Develop an integrated, seamless system that will serve children in the most culturally competent, least restrictive setting, and as close to home as possible. 7
Bring the Kids Home Initiative: Key Strategies 1. Building capacity for lower levels of nonresidential care across the state. 2. Expanding care coordination 3. Addressing systemic funding gaps 4. Improved monitoring of system access, outcomes and service utilization. 5. Organize needed resources and assistance for children and families 6. Develop and maintain a skilled in-state behavioral health work force 8
Bring the Kids Home Initiative: Outcomes Source: Alaska Department of Health & Social Services, Division of Behavioral Health 9
“Developing in-state capacity for children with severe disturbances is only a partial solution… The state must invest in earlier interventions for children and families to keep problems from becoming severe. ” - Alaska Department of Health & Social Services 2007 (Bring the Kids Home Three. Year Update) 10
Service Settings 11
Services for Children and Youth in Out-of-Home Care Behavioral Health Care Therapeutic Foster Care Residential Behavioral Rehabilitation Services Residential Psychiatric Treatment Facility Children may receive more than one of. Care these services, depending on need. Acute 12
Therapeutic Foster Care (TFC) • Agency-supervised, private family homes • Care for children or youth with significant emotional or behavioral problems. • Parents have specialized training to provide individualized, structured services. • Many parents specialize in one area. • Homes are managed by behavioral health agencies. Therapeutic Foster Care 13
Therapeutic Foster Care (TFC) Therapeutic Foster Care Northern (Nome) Presbyterian Hospitality House (1) Interior (Fairbanks) Family Centered Services (9) Presbyterian Hospitality House (10) Statewide Total 222 Homes 485 Beds Southcentral + Kenai AK Child and Family (44) Denali Family Services (57) Hope Community Resources (14) Family Centered Services (5) Kenai Peninsula Counseling Center (3) Presbyterian Hospitality House (26) The Arc of Anchorage (5) Southeast Akeela (5) Community Connections (17) Juneau Youth Services (5) Wil la Mootk Counseling (9) Residential Youth Care (5) Youth Advocates of Sitka (7) 14
Residential Behavioral Rehabilitation Services (BRS) Residential Behavioral Rehabilitation Services • Treat psychosocial, emotional, + behavioral disorders • Three service levels address a range of symptoms + behaviors • Level II: Emergency Assessment and Stabilization • Level III: Residential Treatment • Level IV: Residential Diagnostic Treatment • Always includes family/post-discharge placement unless clinically inappropriate • Types of services offered: case management, therapeutic behavioral health care, support, and medication administration 15
Residential Behavioral Rehabilitation Services (BRS) Northern Nome Community Center Maniilaq Association Interior (Fairbanks) Presbyterian Hospitality House Southeast Juneau Youth Services Residential Youth Care Youth Advocates of Sitka Southwest Yukon Kuskokwim Health Corporation Southcentral + Kenai Alaska Baptist Family Services Providence Health & Services Presbyterian Hospitality House Kenai Peninsula Community Care Center 16
Acute Care Services • Emergency care for children and youth at imminent risk of harm to themselves or others. • Main goal is to stabilize symptoms. • Length of care is 0 to 30 days. • Acute care is provided at psychiatric facilities or in general hospital inpatient settings. • Data presented today for psychiatric facilities covers North Star Acute Care and Alaska Psychiatric Institute (API). • Data presented today for general hospital settings only covers Bartlett Regional Hospital, Fairbanks Memorial Hospital and Providence Alaska Medical Center, Anchorage. 17
Acute Care Services NOTE Interior (Fairbanks) Fairbanks Memorial Hospital All general hospitals provide acute care as possible. The ones noted here are those included in the data set. Southcentral North Star Behavioral Health Providence Health & Services Alaska Psychiatric Institute Southeast Bartlett Regional Hospital 18
Residential Psychiatric Treatment Facility (RPTF) Residential Psychiatric Treatment Facility • RPTF’s serve children and youth who • Exhibit more serious and destructive behaviors, • Have been identified as having more intensive needs, and/or • Need a more structured setting with psychiatric services available and/or a more accurate diagnosis. • Provide highly structured, campus-based, longterm programs for children. 19
Residential Psychiatric Treatment Facility Residential Psychiatric Treatment Facilities Southcentral (Anchorage + Palmer): AK Child & Family Providence Health & Services The Alpine Academy (North Star) The Summit (North Star) Total In. State Capacity = 120 beds 20 Out-of-State Facilities Used in FY 18 20
Data notes … • Data comes from the following sources: • Alaska Medicaid Management Information System, FY 15 -18 • Qualis Health, FY 16 -18 • Office of Children’s Services, FY 16 -18 • Data • Racial groups with less than 10% are grouped with Other or Unknown Race • General hospital inpatient data reflects only 3 facilities: Fairbanks Memorial, Bartlett Regional + Providence-Anchorage. • Data related to types of services may be duplicated as some children receive more than one type of service. 21
Data Labels … Simplified for the purpose of this presentation • AK Native = AK Native/American Indian • Children = Children and youth • Out-of-home care = Out-of-home behavioral health care 22
In which settings are children in outof-home care living? What is the cost? 23
Medicaid Recipients in Out-of-Home Care FY 15 -18 2074 1884 1791 1777 FY 15 FY 16 FY 17 FY 18 Increase of 283 24 Medicaid Data Unduplicated
Medicaid Recipients by Setting FY 15 -18 40% 42% 40% Acute Care 31% Therapeutic Foster Care 37% 28% 20% 15% FY 2015 n=2319 Medicaid Data 27% 20% 19% 14% FY 2016 n=2304 13% FY 2017 n=2424 18% Residential Psychiatric Treatment Facility 11% FY 2018 n=2609 Residential Behavioral Rehabilitation Services 25
Rate of Medicaid Recipients: Acute Care Details FY 15 -18 37% 24% 40% 25% 42% 23% 14% 40% All Acute Care 21% North Star Acute Care 15% General Hospital – Inpatient 8% 9% 5% 5% 4% 4% FY 2015 n=2319 FY 2016 n=2304 FY 2017 n=2424 FY 2018 n=2609 Medicaid Data Alaska Psychiatric Institute 26
Rate of Medicaid Recipients: Acute Care Details FY 15 -18 37% 24% 40% 25% 42% 23% 14% 40% All Acute Care 21% North Star Acute Care 15% General Hospital – Inpatient 8% 9% 5% 5% 4% 4% FY 2015 n=2319 FY 2016 n=2304 FY 2017 n=2424 FY 2018 n=2609 Medicaid Data Alaska Psychiatric Institute 27
Settings and Costs Let’s talk! • Is it surprising that there are more children and youth in out-of-home placements now than in FY 15? Why or why not? • What are the drivers behind the increases in therapeutic foster care and general hospital inpatient care utilization? • What are the drivers behind the decreases in other levels of service? • Are these the changes we want to see? 28
BREAK 29
Who are the children + youth in out-of-home behavioral health care? 30
Gender of Children in Out-of-Home Care FY 15 -18 Count 972 Male n=4058 54% 819 948 829 2015 2016 Female n=3468 46% Female 862 2017 958 2018 Male 4 -Year Average By 59% 55% 52%48% 45% Setting 41% Therapeutic Foster Care Medicaid Data 1022 1116 Residential BRS Female RPTF Male All Acute Care 31
Age Ranges of Children in Out-of-Home Care FY 15 -18 Four Year Average By Year 1119 1076 1084 325 348 353 204 230 242 366 268 205 208 143 0 -7 8 -12 13 -17 18 + years 1232 13 – 17 years 8 – 12 years 18+ years 0 – 7 years 123 2015 2016 2017 2018 n=1791 n=1777 n= 1884 n= 2074 32 Medicaid Data
Age and Setting of Children in Out-of. Home Care FY 15 -18: Four-Year Average Therapeutic 57 Care* Foster 60% 1% 18% 0 -7 8 -12 13 -17 18 -20 years Residential BRS* 79 Acute Care 13% 54% % . . 2. 18 - 1. . . 8% 13 - 01 2. . . 13 % 10% 20% 16% 0 -7 8 -12 13 -17 18 -20 years * Breakdown of 1 -12 age group not available Medicaid Data 5% 0 -12 13 -17 18 -20 years 18% 0 -7 8 -12 13 -17 18 + years 76% % 34 % 9% 9% RPTC 33
Race of Children in Out-of-Home Care by Setting FY 15 -18: Four-Year Average AK Native Acute Care n=3619 42% RPTF n=1845 34% 48% Therapeutic Foster Care n=2716 50% 0% 20% Other/Unknown 12% 11% Residential BRS n=1257 Medicaid Data Multi-Racial 13% 34% 13% 42% 11% 9% 13% 40% White 60% 9% 32% 28% 80% 100% 34
Race of Children in Out-of-Home Care, FY 18 Compared to Total Child Population in Alaska, July 2017 55% 20% 14% 12% 43% 11% 13% 33% AK Native Multi-Racial Other or Unknown Race White Medicaid Data FY 18 Medicaid Recipients in Out-of-Home Care n= 2074 Alaskans 0 -19 by Race as of July 2017 n= 206, 448 35
FY 15 to FY 18 1199 619 595 Rates and Types of Substantiated Allegations 21% Office of 17% Children’ 9% s Services Data Office of Children’s Services Data Neglect Emotional Abuse Physical Abuse Sexual Abuse 4 Ov 0 er 41 5 to 30 31 31 to 20 21 to 0 11 6 t o 1 10 9 8 7 6 o 5 5 Counts of Allegations 52% 147 138 122 118 103 1 t 4 3 249 246 212 186 2 306 1 Allegatio ns of Abuse among Children in RPTF and Acute Care 85% of children receiving residential psychiatric treatment or acute services have had one or more allegations of abuse. 36
Children in Out-of-Home Care Let’s talk! Medicaid Data • What are the causes of the overrepresentation of Alaska Native children in out-of-home care? • Given that 85% of children in outof-home care have had an allegation of abuse, what are the barriers to earlier intervention? • What are the barriers to increasing capacity to serve young children in residential settings in Alaska? 38
Children Receiving Therapeutic Foster Care Services 39 Medicaid Data
Unique Medicaid Recipients Therapeutic Foster Care FY 15 -18 809 647 FY 15 617 643 FY 16 FY 17 FY 18 Increase of 162 40 Medicaid Data
Demographics Therapeutic Foster Care FY 15 -18, Four-Year Average Gender Race 59%. . . 41% 28% Age . . . 9% 13% 18+ years 13% 13 -17 years 8 -12 years 0 -7 years . . 60%. 50% 18% 9% 41 Medicaid Data
Therapeutic Foster Care Let’s talk! • Can existing therapeutic foster homes meet the need for services across Alaska? • Which region(s) are most in need of more TFC services? • Do providers have the right specializations for the population? (young children, cognitively impaired, etc. ) • Do you think families and service providers, including private providers know how to find TFC services? 42
LUNCH 43
Residential Behavioral Rehabilitation Services 44
Residential Behavioral Rehabilitation Services Unique Medicaid Recipients FY 15 -18 341 318 304 294 FY 15 FY 16 FY 17 FY 18 Decrease of 47 45 Medicaid Data
Residential Behavioral Rehabilitation Services Medicaid Payments FY 15 -18 (data rounded) $6, 000, 000 $5, 000 $4, 000 FY 15 n=341 Medicaid Data FY 16 n=318 FY 17 n=304 FY 18 n=294 46
Demographics FY 15 -18, 4 -Year Average Gender Male Race 55% Female AK Native 45% Multi-Racial Other/Unknown Age 18 -20 years 11% 9% 32% 8% 13 -17 years 0 -12 years White 48% 79% 13% 47 Medicaid Data
Residential Behavioral Rehabilitation Services (BRS) Let’s talk! • Statewide, is there sufficient supply of BRS services to meet demand? • Which region(s) are most in need of more BRS services? • Do you think families and service providers know who to call for BRS services? • The residential BRS program is serving fewer children. Is this beneficial, or not, to the out-ofhome care continuum? 48
Acute Care 49
Acute Care Services Unique Medicaid Recipients 956 802 FY 15 860 FY 16 FY 17 Increase of 199 Medicaid Data 1001 FY 18 50
Acute Care Details 37% 24% 40% 25% Acute Care Services 42% 23% 14% 40% 21% 15% 8% 9% 5% 5% 4% 4% FY 2015 n=2319 FY 2016 n=2304 FY 2017 n=2424 FY 2018 n=2609 Medicaid Data All Acute Care North Star Acute Care General Hospital – Inpatient Alaska Psychiatric Institute 51
Unique Medicaid Recipients by Provider FY 15 – FY 18 556 576 556 546 400 346 197 214 112 124 FY 15 FY 16 108 FY 17 Acute Care Services North Star Acute Care General Hospital In-Patient 103 FY 18 Alaska Psychiatric Institute 52 Medicaid Data
Medicaid Payments Acute Care Services FY 15 – FY 18 Total Medicaid Payments $15, 000 North Star Acute Care $13, 000 $12, 000 General Hospital – Inpatient $6, 000 $4, 000 $3, 000 FY 15 n = 865 FY 16 n = 914 FY 17 n = 1010 Alaska Psychiatric Institute FY 18 n = 1049 53 Medicaid Data
Length of Stay (Days) 4 -Year Average by Acute Setting 32 21 11 General Hospital - Inpatient North Star Acute Care Alaska Psychiatric Institute 54 Medicaid Data
Demographics, Four-Year Average Acute Care Services Gender Male 48% Female Race 52% AK Native Age 18 -20 years 16% 13 -17 years 8 -12 years 0 -7 years 42% Multi-Racial 12% Other /Unknown 13% White 34% 54% 20% 10% 55 Medicaid Data
Change in Admission by Age, Acute Care Services FY 15 +18 14% increase 527 464 38% increase 314 45% increase 228 160 110 0 -12 years 13 -17 years FY 15 n = 802 18 -20 years FY 18 n = 1001 56 Medicaid Data
Changes in Admission by Race FY 15 and FY 18 Acute Care Services 20% increase 13% increase 20% increase 347 418 AK Native 96 115 Multi-Racial FY 15 n = 802 93% increase 72 144 Other or Unknown Race 287 324 White FY 18 n = 1001 57 Medicaid Data
Acute Care Let’s talk! • What are the drivers behind the increase in admissions to general hospital settings? • Is this increase beneficial, or not, to the out-of-home care continuum? • If the need for acute care indicates a crisis for adult caregivers, how do we strengthen their ability to manage and stabilize crises with children? 58
BREAK 59
Residential Psychiatric Treatment Facilities 60
Residential Psychiatric Treatment Facilities Annual Client Counts, FY 01 – FY 18 752 Decrease of 85 in-state Increase of 68 out-of-state BTKH Initiative 303 381 266 301 192 213 186 201 248 234 254 218 112 FY 01 FY 03 FY 05 FY 07 FY 09 FY 11 FY 13 Total In-State Total Out-of-state FY 15 FY 16 Total In-State FY 17 FY 18 Total Out-of-State 61 Medicaid Data
Residential Psychiatric Treatment Facilities Medicaid Payments FY 15 – FY 18 $18, 000 $17, 000 Out-of-State Payments In-State Payments $13, 000 $11, 000 FY 15 n = 466 FY 16 n = 455 FY 17 n = 467 FY 18 n = 457 62 Medicaid Data
Residential Psychiatric Treatment Facilities Demographics FY 15 -18, Four-Year Average Sex Male Race 55% Female 45% AK Native Multi-Racial Ages 18 -20 years White 5% 13 -17 years 11% 13% 42% 76% 8 -12 years 0 -7 years Other/Unknown 34% 18% 1% 63 Medicaid Data
19 to 20 Ages at Admissio n by Location (FY 1618) Residential Psychiatric Treatment Facilities 1% 0% 23% 16 to 18 32% 40% 13 to 15 57% 26% 10 to 12 Under 10 10% 0% Out-of-state n=462 Qualis Data In-state n=516 64
Race at Admissio n by Location (FY 1618) Residential Psychiatric Treatment Facilities 39% White 49% 47% AK Native/Am Indian Other 34% 14% Out-of-state n=439 16% In-state n=501 65 Qualis Data
Discharg e Placeme nt (FY 1618) Residential Psychiatric Treatment Facilities Qualis Data Home with Clinic or In-Home Suppport 60% Inpatient Psych 10% Foster Care or FTH 6% Left Against Medical Advice 5% Discharged to Correctional Facility 5% Residential Psych 4% Discharged to Group Home 4% Another Acute Care Hosp 4% Home 1% Unknown 1% Deceased 0% 66
Top Two Primary Reasons for Placement (FY 16 -18) Residential Psychiatric Treatment Centers Aggression to Self/Others Suicidal Ideation/Attempt In-state n=784 33% 47% 55% 26% Out-of-state n=702 Reasons for Placement less than 10% include dual diagnosis, sexual acting out, requires locked facility, homicidal ideation/attempt, self-mutilation, and eating disorder. Qualis Data 67
Aggression Top 8 Risk Factors (FY 16 -18) Family History Substance Abuse 45% 40% Out-of-state n=702 60% 47% 44% Flight Risk Property Destruction 60% 54% 47% Family Medical History Self Mutilation Qualis Data 61% 65% Suicide Risk Non-Compliance with TX Residential Psychiatric Treatment Facilities 55% 80% 31% 60% 38% 47% In-state n=784 68
Top Three Psychosoci al Factors (FY 16)** Problem With Primary Support Group 22% Problem Social Environment 22% 21% 20% 17% Educational Residential Psychiatric Treatment Centers Out-of-state n=619 In-state n=528 Factors less than 15% include legal, housing, access to health care, economic and occupational. ** Data for FY 17 -18 not shown. This data was not consistently entered during these years. 69 Qualis Data
Top four diagnostic groups Diagnost ic Groupin gs (FY 1618) Residential Psychiatric Treatment Facilities 33% 25% Anxiety Disorders 30% 27% Mood Disorders Neurodevelopmental Disorders Out-of-state n=702 Qualis Data 22% Schizophrenial Spectrum and Other Psychotic Disorders 22% 17% 13% In-state n=784 70
Traumas (FY 1618) 51% 47% Emotional Abuse Multiple Placements 44% 48% Witnessed Domestic Violence Physical Abuse 40% Neglect Residential Psychiatric Treatment Facilities 38% 18% 21% 11% Death/Suicide Qualis Data 50% 28% 27% Adopted Multiple Losses 90% have experienced trauma. 48% 34% 35% Sexual Abuse Natural Disaster 53% 43% 17% 0% 10% Out-of-state n=702 20% 30% In-state n=784 40% 50% 60% 71
Mood Disorder Comorbidi ty (FY 1618) 61% Thought Disorder 18% Substance Abuse 18% Suspected FASD Eating Disorder 74% have a diagnosed comorbidity Brain Injury 33% 26% 21% 17% Developmental Disorder Residential Psychiatric Treatment Facilities 75% 9% 18% 12% 8% 5% 6% 4% 2% Out-of-state n=702 In-state n=784 72 Qualis Data
Other Factors (FY 1618) 41% Individualized Education Plan 32% 36% Fetal Alcohol Spectrum Disorder or Probable FASD 23% 19% Intellectual Developmental Disability Residential Psychiatric Treatment Facilities IDD Waiver Out-of-state n=702 6% 17% 1% In-state n=784 73 Qualis Data
Residential Psychiatric Treatment Facilities (RTPF) Let’s talk! • Why are we seeing an increase in out-of-state placements and a decrease in in-state placements? • What are the causes in the racial disparity between in and out of state placements? • Given the high rate of trauma and co-morbidity, what are the barriers to earlier intervention? 74
Small Group Discussion 75
Small Group Discussion • What are the top three takeaways from today’s discussions? • What are the top three goals we should work towards related to children in out of home care? • Which data indicators should we track? 76
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