The Children's Behavioral Health SMART Model of Car

The Children’s Behavioral Health SMART Model of Care Ensuring Access to Earliest Intervention for Hawai‘i’s High-Risk Children Birth Through Five Years Ira J. Chasnoff, MD GG Weisenfeld, EdD

The Children’s Behavioral Health SMART Model of Care The purpose of this report is to describe the outcome of a one-year communitybased planning process to develop a model of behavioral health care for Hawai‘i’s children, ensuring that all high-risk children birth to five years of age throughout the state will have full access to early identification, comprehensive assessment, and a full range of therapeutic services.

The SMART Model of Care has been developed through a partnership between Hawai‘i Community Foundation and Hawai‘i’s State Departments of Health, Human Services, and Education as well as the Zero to Three Courts, the Health Care Transformation team in the Office of the Governor, and the Hawai‘i Primary Care Association. The Model of Care represents the dedicated work and leadership of these agencies.

What do we know?

The early years are the most important. We know this much is true: the first few years of children’s lives are vital for their ultimate growth and development. During this time, the basic difficulties that define life-long mental health, developmental, and learning problems can begin to emerge.

We also know that a child’s development is a dynamic process, involving both social and biological factors that contribute to success or failure. From day one, the child interacts with the surrounding environment and seeks the nurturing support that will help him achieve full potential for growth and development.

Thus, behavioral health problems can emerge from a wide variety of biological and environmental factors. Just as premature birth, prenatal exposure to alcohol or drugs, or poor maternal nutrition can harm fetal brain development, family violence, substance abuse in the family, or maternal depression can interfere with the child’s brain development after birth. The problems that emerge as the child enters school leave the child unprepared for learning.

Right now in Hawai‘i, children who need early intervention for developmental and behavioral health problems are not identified until they are older; the best opportunity to help them has been missed. Experienced professionals point out that many children are struggling in school with problems that could have been addressed much earlier. Others point to children who get in trouble with the law and know that their difficulties could have been identified much earlier in life and steps taken to help them avoid developing serious and perhaps lifelong problems.

Children with developmental or behavioral health problems who are identified early in life and receive the services they need have a better chance to develop to their full potential – at home, in school, as an employee and as a citizen.

However, the human benefit to the child is not the only benefit. Families benefit when children are helped early on in life because this avoids school difficulties and behavioral problems. Schools benefit - ask any teacher about the 2|P a g e

disruptions in the classroom due to children who have difficulty controlling their behavior. The foster care system will benefit if there are fewer placements needed to find a child a home. The State benefits from having more children functioning well in the normal settings of life and fewer occupying Dependency Court, Special Education classrooms and the corrections system.

The benefits are both human and financial.

“High-risk” children are those children who have exposure to risk factors that are known to lead to problems in living. For example, children born to mothers who used tobacco, alcohol and/or illicit drugs during pregnancy are at risk for developing developmental and behavioral problems. Exposure to domestic violence, poverty, neglect and abuse are other risk factors that add to the complexity of life for many of Hawai‘i’s children. An estimated 20% of children in the US have a diagnosable behavioral health condition, and about 2%-5% suffer from a serious behavioral health disorder that causes substantial impairment in functioning at home, at school, or in the community.1 There is no reason to think that these numbers do not apply in Hawai‘i.

There are social and fiscal ramifications for society when children are not identified early and provided appropriate care. These children typically display more aggressive and disruptive behavior that places them on a trajectory associated with a range of negative life outcomes in youth and early adulthood.2 On the other hand, when children are identified as needing behavioral health services early and receive the appropriate care, they are3:  Less likely to receive psychiatric inpatient services [savings of $1,433 per day4]  Less likely to visit an ER for behavioral and/or emotional problems [savings of $165 per visit5]  Less likely to be arrested [savings of $4,142 per month per child6]  Less likely to repeat a grade [$10,736 per child7]  Less likely to drop out of school [$41,369 per youth8]  Less likely to be arrested as a juvenile [$5,656 per arrest9]  More likely to remain in a foster care placement [savings of $1,790 per month per child10] Children with serious behavioral health conditions incur costs in multiple child-serving systems, including mental health care costs, MEDICAID, TANF, high school drop out costs, and child welfare costs. Colorado calculates that early intervention produces a reduction of 40% of projected future expenditures, making the Return on Investment (ROI) $1.80 per each dollar spent on children under the age of 511.

Hawai‘i’s children are at risk for severe problems of developmental, behavioral, mental health, and social/ emotional functioning due to a wide range of factors (Kids Count Data Center, 2014; HYIPR Report FY 2013, DHS/CWS Annual Progress Report, 2014): • 1,542 children were low birth weight (8.1% of total births) 3|P a g e

• • • • •

101 children died by age one (2011) 46% of children entering foster care entered by age 5 893 children were in foster care under the age of 5 in 2013 Over 700 young children were confirmed abused/neglected in 2013; 46% were under 1 year of age 3.5% of infants and toddlers participated in Early Intervention [majority for speech/language]

The planning process Responding to the issues facing children and families in Hawai‘i, Hawai‘i Community Foundation (HCF) led the effort to develop a Model of Care for high-risk children throughout the state. HCF organized a team of state leaders from the public and private sectors to assess the current status of children in Hawai‘i, examine departmental and agency approaches to a variety of factors that impede appropriate behavioral health development, and develop an overarching strategy to promote the early identification and treatment of high-risk children and their families. The team reflected a public-private partnership and crossed organizational and professional boundaries:  Hawai‘i Department of Health o Family Health Services Division o Children with Special Health Needs Branch  Hawai‘i Department of Human Services o Child Welfare Services Branch o Med-Quest Division (Medicaid)  Hawai‘i Department of Education  Hawai‘i Zero to Three Court, Family Court, First Circuit  Health Care Transformation Project, Office of the Governor  Hawai‘i Primary Care Association.

Governance of the planning team was guided by a core set of principles agreed to by all team members.

1. The Leadership Group: a. is a voluntary collaboration between interested public and private/community sector stakeholders b. can add representatives of other stakeholders by consent of the group c. is not a governmental body and is not subject to Sunshine Laws 2. The Leadership Group: a. provides leadership to advance the group’s vision and mission b. makes recommendations to: a. improve access to and quality of behavioral health services to children ages 0 to 5 years old in Hawaiʻi b. coordinate between agencies/entities to eliminate gaps and duplication of services, leverage available funding more effectively, and create smoother, more effective

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3.

4.

5.

6.

transitions between caregivers for children needing services and their families. c. holds each other accountable for forward progress to achieve agreed goals Duration: a. Anticipated life span of the Leadership Group is 3 to 5 years, unless terminated sooner by the members of the group b. Frequency of the meetings and progress goals/milestones are to be determined by the group.

Authority of the Leadership Group: a. The Leadership Group has the authority to convene meetings, set agendas, decide meeting procedure, amend these ground rules, and terminate the existence of the Leadership Group b. The Leadership Group has no authority to make any decisions for any of the agencies/entities represented in the Leadership Group.

Each agency/entity retains its own independent authority to make decisions about and implement the recommendations of the Leadership Group.

Decision-making process: a. Decisions of the Leadership Group preferably will be made by consensus. However, the Leadership Group may decide to have specified agenda items decided by a vote of individual members. b. Decisions of the Leadership Group are recommendations only and are not binding on the member agencies/entities belonging to the Leadership Group. c. Silence = acquiescence.

In other words, members who say nothing about an agenda item are assumed to be in agreement with the decision of the group. d. A written record of decisions by the Leadership Group may be retained for internal use of the group and for individual member organizations to understand and implement recommendations.

Governance structure: a. The Leadership Group may create subcommittees or other advisory groups to work on specific topics or tasks as directed by the Leadership Group, consisting of designated staff from each department or entity represented in the Leadership Group and other experts and stakeholders by invitation. b. Any such subcommittee or other advisory group shall be subject to these ground rules. c. All recommendations from all subcommittees and advisory groups shall be subject to final review and approval by the Leadership Group.

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7. Record-keeping and confidentiality: a. The meeting discussions, meeting materials and notes, and related emails and communications: a. are for the use of members of the Leadership Group and their respective staff b. are not intended for publication or dissemination outside the Leadership Group unless approved in advance by the Leadership Group b. Formal meeting minutes and record keeping are not required.

Each member is expected to keep his or her own records of the meetings and materials related to the work of the Leadership Group.

8. Role of the Hawaiʻi Community Foundation a. To convene and facilitate meetings of the Leadership Group b. To support the work of the Leadership Group with research and analysis at HCF’s option, including support for the research and advisory work provided by Dr. Ira Chasnoff and GG Weisenfeld as contractors of HCF.

Theoretical Framework The specific aim of this initiative is to build a system of care through which all children in Hawaiʻi birth to 5 years of age have access to the interventions and therapeutic services they need to support the children’s achieving their full potential.

Shared values A core set of shared values shape the planning team’s thinking: • Systems improvement must reflect the needs of children and their families, be simple, and be easy to access.

• Statewide access is vital.

• The system needs to embrace cultural practices and place value on cultural diversity and competence.

• Early Intervention, especially before the age of 6, benefits children the most.

• Evidence-based practices provide the best opportunity for improving outcomes of children and families.

• Financial sustainability will be built on primary and secondary payors and on public and private sector financial support.

• The system will not be dependent on individuals within departments, but will survive change in leadership over time.

Definitions Based on these values, it was recognized that successful early childhood development must be defined as broadly as possible. Behavioral health encompasses social, emotional, behavioral, and relational development as well

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as motor, speech and language, etc. Thus, as we seek to identify and intervene with all children at risk in Hawaiʻi, this broad definition guides our thinking.

It also was recognized that children can be found throughout the community, not just in specific, narrowly defined settings. Thus, a second task was to take a broad view of children’s lives in Hawaiʻi, considering the narrow gates where children gather throughout the islands. These narrow gates include places where medical, social service, and educational services are provided, as well as other community-based primary sites of contact in which children can be found.

Community-based is the preferred term for the approach taken because it places a special emphasis on the breadth of the effort. It is not narrowly medical, though it depends heavily on the community’s physicians and other health care providers. It is not a public health initiative alone, though the role of public health professionals and outreach workers is essential. It is not driven by mental health treatment, per se, but does recognize the importance of quality treatment capabilities throughout the community. It is not powered by the authority of the courts, though the effort would be missing an enforcement element if the courts were absent. Similarly, the business community, the church community, the schools all have a stake in the success of the effort and will play an important role. The important point is that the authority of the approach comes from the broad base upon which it rests and in which it is rooted.

SMART: The Core Intervention SMART is an acronym that stands for screening, decision-making, assessment, referral, and treatment.11 It is the “core intervention” that the planning process sought to establish in the community.

Screen

decision Making

Assess

Screen all children for behavioral health risk. Largely this is accomplished by becoming a fixed part of primary health care for pregnant women and children’s primary health care as well as outreach into multiple narrow gates around the community.

Make a decision within the primary screening site as to whether immediate early intervention will provide the support and services the child needs or whether the child needs to move to higher levels of intervention.

Those children who screen positive are given an appropriate level of assessment to determine service and intervention needs.

Refer

Those children who require higher levels of care are referred up through a linked and integrated system.

Treat

Those children who are referred to each level of intervention and treatment receive quality, evidence-based treatment that is appropriate for the child’s and family’s circumstances.

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Levers of change One of the team’s first steps in the planning process was to identify and then prioritize the top 3 levers of change to implement the system:  Establishing a joint goal, “vision statement” to which all are committed  Map interventions available at each level of the system, examining issues of o Coordination o Accessibility o Screening and earliest intervention o Costs across total system  Examine and resolve barriers to data sharing o Federal definition o Lack of data system o Consent process as needed o Standardization of screening tools

Research and Investigation for Background Information The team’s work was supported by data and information collected through a variety of surveys and investigation of existing public and private agency services, policies, and procedures.

Site visits In January 2015, the Hawai‘i Community Foundation sponsored site visits to three programs developed through a similar planning process and successfully operating SMART systems of care: • Cradle to Crayons [Phoenix, AZ] • MCSTART [Monterey, CA] • Desert Mountain Children’s Center [Apple Valley, CA] Cradle to Crayons (C2C) is housed in the Arizona County Judicial system and serves children birth to three years in the foster care system. Three renovated buildings connected to the courtrooms offer space for visitation, child and family therapy, substance-abuse treatment, and early education services.

Selected court judges have received special training in early childhood development and handling cases with children under age 3 years. With an annual budget of approximately $2 million, the C2C Judges were able to dismiss dependency cases on 399 children in FY 2014, with an average case age for dismissed children during this time period being 533 days. These data are significantly better than the overall population of the Juvenile Court Bench, which dismissed dependencies in 282 children during that same time period with an average case age of 907 days.

MCSTART is a children’s behavioral health clinic housed in Door to Hope, a 501 (C)(3) that initiated children’s services in 2003. Medicaid (EPSDT), child welfare (Title IVE), substance abuse block grant monies, and private

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foundation funding support MCSTART’s public/private partnership budget of $2.9 million. Clinical staff members, consisting of a physician, physicians’ assistant, child psychologist, 5 doctorate level therapists, an occupational therapist, 6 parent educators, 4 case managers, and 15-20 mentor parents, serve 400-450 children per year through a transdisciplinary approach.

Desert Mountain Children’s Center (DMCC) is a clinical services program housed within San Bernardino County’s Department of Education and is governed by the school district’s 15 school superintendents. Medicaid (EPSDT), department of education, department of health (Title V) and private foundation funding support the program’s annual budget of $2.5 million. Public health nurses conduct outreach and screening throughout the community, and children move through a series of increasingly complex levels of service.

DMCC providers conduct complex assessments that include evaluation of medical, developmental, psych/social, occupational therapy and speech and language status. Based on the assessment, recommendations are made to the parent/guardian of the child and appropriate referrals are instituted. On site at DMCC, a variety of treatment services are available: Individual/Family Psychological Therapy, Parent/Child Interaction Therapy (PCIT), Theraplay®, Play Therapy, Occupational Therapy / Sensory Processing, and Speech and Language Therapy.

From a funding perspective across the three programs, costs/child for services covered a wide range: $2500 to $5450. However, Medicaid EPSDT (Early Periodic Screening, Diagnosis and Treatment) funding covered a significant amount of this cost and can be a core source of funding for sustainable clinical services. In addition, Title IV-E funding through the child welfare system can be a source of funding for training of professionals and training and supporting foster, adoptive and biologic parents. Title V federal funding through the state’s Maternal and Child Health office provides enhanced outreach and support services for Medicaid eligible pregnant and parenting women.

Prenatal Risk Data Dr. Ira Chasnoff and NTI Upstream have been working in Hawai‘i to address substance use in pregnancy since April 2007. At that time, a team of community leaders invited Dr. Chasnoff and his team to guide the development of a comprehensive model of prevention and intervention for families on Hawai‘i Island. The team membership brought together representatives from various agencies and community health centers, as well as community-based professionals in pediatrics, early childhood education, hospital administration, mental health, schools, substance abuse treatment, tobacco cessation, and child protection.

As a result of that planning effort, pregnant women enrolled in prenatal care throughout Hawai‘i Island for the past eight years have been screened with the 4P’s Plus, a validated, published screening instrument that identifies pregnant women at risk for alcohol, tobacco, and illicit drug use. In 2012, through funding

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from the Hawai‘i Community Foundation, the screening program was expanded to include sites on Oahu, and in 2014, outreach added Maui and Moloka‘i. Those women with a positive screen undergo a more thorough structured clinical intervention conducted at the same prenatal visit and receive a brief intervention to educate them about substance use and then, as appropriate, a referral to treatment. Widely published data have demonstrated the success of this approach, and the federal government’s National Prevention Task Force recommends that this strategy be utilized for all individuals enrolled in prenatal care.

On Hawai‘i Island and Oahu, as of May of this year, 6,879 pregnant women have been screened. The majority of the women screened are in the 19 to 34 years age range, with 18% adolescents, and 9% of the women 35 years and older. In response to the 4P’s Plus© screening questions, 26% of all women in the participating sites admitted to tobacco use, 30% admitted to alcohol use, and 9% admitted to illicit drug use. Native Hawai‘ian women and Caucasian women have the highest rates of using alcohol, and Native Hawai‘ian women have the highest rates of tobacco use. For the entire population of women enrolled in the study, 35% were using a substance that affects the structure and function of the developing fetal brain.

Children’s Behavioral Health Risk In response to multiple requests for help from Hawai‘i’s families, Dr. Chasnoff and his team operated a free clinic on Hawai‘i Island. The purpose of this clinic not only was to provide direct assessment and treatment services to children in Hawai‘i, but also to try to get a first picture of the behavioral health difficulties among children in the islands. The clinic was held on Hawai‘i Island, one week at a time, three times per year for three years. Dr. Chasnoff brought a nurse and a clinical psychologist from the mainland with him on a volunteer basis. Local pediatricians provided space for the clinic in their offices at no cost. Histories were collected on all cases referred to the clinic, and the children were selected for assessment based on their acute need and the likelihood that the assessment could provide them with a treatment plan that would improve their current status.

Over 100 children were referred to Dr. Chasnoff by Hawai‘i pediatricians, courts, and child welfare in 2011-2013. Of these children, 65 were selected to undergo a comprehensive assessment. The children primarily came from Oahu, Maui, and Big Island. A random sample of 22 children ranged in age from 4 months to 16 years. Behavioral problems were the primary reason for referral. Of the 22 children, 10 met criteria for a diagnosis within Fetal Alcohol Spectrum Disorders, 6 had significant intellectual disabilities, 4 were diagnosed with attention deficit hyperactivity disorder (ADHD), and 13 had a significant mental health disorder.

None of the 22 children had ever had a full evaluation. When comparing the multiple diagnoses that had previously been given to the children to the diagnoses that resulted from the comprehensive assessment, 18 (82%) had

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been misdiagnosed. This high rate of misdiagnosis is consistent with the 85% rate of misdiagnosis documented in a recent study of children in Illinois published by Dr. Chasnoff and his colleagues in February 2015 in Pediatrics.

In examining the children’s histories, several common reasons for the high rate of misdiagnosis emerged: • Failure to identify risk factors, such as alcohol and drug use, in the prenatal period. Pediatricians especially are unaware of the mother’s use of alcohol, tobacco or illicit drugs during the pregnancy.

• Lack of children’s primary care providers’ ability to recognize risk and know what to do for a child at risk for behavioral and mental health disorders.

• High rate of co-occurring mental health disorders.

• Lack of assessment across all domains of child functioning.

• Limited treatment resources forced inappropriate use of medications to address any behavioral or mental health problems.

• Multiple moves within the child welfare system resulting in constantly changing educational placements and health care providers.

• Perceived stigma against mental health and substance abuse disorders in families.

Survey of Hawai‘i’s Clinical Programs for Children A survey was designed to examine the degree to which programs in Hawai‘i are implementing the components of a SMART system of care. The survey was distributed in January 2015 to 86 agencies across the state. Research of websites associated with Aloha United Way Search 211; Hawai‘i Department of Human Services and Department of Health; Children, Adult, Mental Health Division (CAMHD) grantees; Early Intervention providers; and Home Visiting contractors provided the list of potential participants. In addition, each of the six Head Start/Early Head Start grantees and the 14 FQHC providers were sent a survey. Programs were emailed a weblink that would connect the programs to the on-line survey. Confidentiality of specific programs was ensured.

After the initial response, follow up phone calls and emails were sent to programs to answer any questions and remind them to complete the survey.

For several programs, the data were collected during a phone conversation and manual entries were made.

Sample Forty-six surveys were completed. Nine of the programs responded that they served children over the age of 8 and were therefore excluded from the sample. The remaining 37 respondents were sorted; seven more were excluded from further analysis: 3 because they do not provide direct services but serve as advocacy agencies and four because they had incomplete surveys. The final sample that was analyzed was comprised of 30 agencies.

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These 30 agencies represent a wide range of programs that varied in the number of children age birth to eight served annually [10 to 5000], the number of sites at which services were offered [1 site to 38 locations], and the overall size of the agency. The respondents ranged from statewide, very large multiservice agencies that served a large number of zip codes to smaller therapeutic settings that served one zip code. Collectively, the 30 agencies serve over 25,000 children (birth-8) annually.

Methodology and data analysis All of the programs’ responses were scored based on the degree to which they implemented SMART components. There is no viable methodology for measuring “decision making” through a survey approach, so only the action components (screening, assessment, referral, treatment) were included in the programs’ evaluation. Each of the four action steps was given one of three scores: a blank rating [they did not provide this service]; a lower case letter: they provided this service but not to the degree necessary for a high-quality SMART system; or an upper case letter: they provided the component necessary for SMART quality (Table 1). Dr. Weisenfeld assigned these codes to each program in the sample based on the self-reported data submitted by the survey responder.

Table 1. Scoring System for Clinical Program Survey Did not Provides this component Provides this component provide this but not to the degree necessary for SMART component necessary for SMART quality quality Screening No rating Rating: s Rating: S Screens children, but Screens children using a did not use a valid or valid and reliable tool. reliable tool Assessment No rating Rating: a Rating: A Assesses children but Assesses children using a does not include a clinical interview, and/or clinical interview, instruments, and/or and/or instruments, multi-disciplinary team. and/or multidisciplinary team.

Referral No rating Rating: r Rating: R Makes referrals to Makes referrals and has a programs, but does not procedure for tracking have a system in place child’s entry into the to track child’s entry into program. the program.

Treatment No rating Rating: t Rating: T Provides treatment but Provides treatment using does not use published published evidencedevidenced-based based therapies. therapies.

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After the programs were assigned a code, the surveys and results were reviewed and verified by Dr. Chasnoff. Any disagreement between the two coders was resolved through consensus.

Results The following table summarizes the data obtained through the survey for the 30 programs.

Do not provide this component

Screening Assessment Referral Treatment

8 12 8 10

Provides this component but not to the degree necessary for SMART quality 7 14 13 13

Provides this component necessary for SMART quality 15 4 9 7

Screening 22 programs responded that they screen children. The most common tools used were Ages & Stages-III (ASQ) and Ages and StagesSocial Emotional (ASQ-SE). However, not all children within the programs are screened; rather, the programs select which children will be screened, often after a clinical assessment. Formal screening instruments were more likely to be implemented in center-based programs, such as Head Start and family child interaction programs (FCIL)12 programs, whereas in federally qualified Community Health Centers, a clinical interview approach more typically is used to screen the children. Statewide, the estimated number of children screened is about 30%.

It should be noted that in the past five years numerous statewide workgroups have been organized to address children’s developmental screening: • Action Strategy: Team 3 (Governor’s Office) • American Academy of Pediatrics: Building Bridges • Child Mental Health Initiative (DOH) • Early Childhood Comprehensive Systems: Screening Management Team (DOH) • EPSDT Workgroup (DHS) • Hawai‘i Child Welfare Services-Program Improvement Plan (PIP2) Steering Committee (DHS) • Hawai‘i Wrap Services Project Coordinating Committee (DHS) • Healthy Child Care Hawai‘i (DOH, UH) • Hui Kupa`a Collective Impact (Governor’s Office & Phocused) • Maternal Child Health Workforce Development (DOH) • Screening and Assessment Workgroup (CWSB, DHS) • Title V Screening Work Group (DOH)

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Most of these workgroups identified valid screening tools to be used for screening; however, different tools were selected by different workgroups. For those recommending the same instrument, there is not a consistent cut-off score used to determine when children need services, nor are there common protocols or policies for screening and referring children who are positive. In addition, children often are screened multiple times. For example, when children leave IDEA Part C [Early Intervention, DOH] and enter IDEA Part B [SPED, DOE] they are re-screened. When children are screened in Head Start, they are re-screened by the pediatrician, sometimes using the same tool. This results in a significant amount of money and energy being used up by screening efforts, depleting resources for needed assessments and treatment.

The lack of a unified data system or even simple protocols for communication across departments and systems leads to this inefficiency and ineffectiveness.

Assessment There is no central definition of what an assessment means.

Therefore, many groups state they are assessing children, but they are actually using screening instruments. What assessments occur tend to be focused on the particular expertise of the provider.

Referral Referrals from one agency to another appear to be occurring; however, there is no system to track children to ensure that they follow through on the referral and subsequently receive the appropriate and defined treatment identified in their assessment plan. As one provider stated in the survey, “Our challenge is that we have no tracking, nor metrics to provide details on this population.”

Treatment Most programs that provide treatment are not using evidence-based models. A limited number of providers are using evidence based treatment approaches, but in many cases they are using them with populations for which the program was never intended. Less than 25% of the programs we surveyed offered high-quality treatment, and these programs only serve 739 children collectively.

Survey of State Departments and Agencies In order to better understand the clinical landscape in Hawai‘i, each member of the Leadership Group was asked to identify all the “narrow gates” through which children ages 0-5 pass within their department/agency. In addition to identifying the narrow gates, a template was provided to collect specific information about what if any child screening occurs at this narrow gate. If developmental screening does occur, addition information was requested:  Professional background, discipline of personnel conducting the screening  Number of children screened per year  Instruments or approaches used for screening  Other organizations that might assist in the screenings  Geographic location of screenings  Training and professional developmental opportunities for screeners 14 | P a g e

   

Quality assurance methods Monitoring of contractors Follow up, including brief interventions, provided to children who screen positive Tracking system for screening and referral data

Ten “narrow gates” were identified across the agencies and departments; however one of the gates was a system effort that does not directly serve children(*):          

Child Welfare Services [Department of Human Services] Med-Quest (Medicaid) [Department of Human Services] Family Court, 1st Circuit [State Judiciary] Special Education Section [Department of Education] Executive Office on Early Learning [Department of Education] Early Intervention [Department of Health] Early Childhood Comprehensive Systems [Department of Health]* Home Visiting Unit [Department of Health] Child, Adolescent, Mental Health Division [Department of Health] West Hawai‘i Community Health Center [Federally Qualified Health Center]

Analysis of the data collected through the survey indicated that among the responding agencies administered by Leadership Group participants, approximately 90,000 children birth to age five living in Hawai‘i pass through a “narrow gate” and have an opportunity for screening. The “narrow gate” through which the largest percentage of children pass is Med-Quest (Medicaid). Other gates see much fewer children: Division/Program/Office Child Welfare Services Med-Quest (Medicaid) Family Court, 1st Circuit Special Education Section Executive Office on Early Learning Early Intervention Home Visiting Unit Child, Adolescent, Mental Health Division West Hawai‘i Community Health Center

Number of Children (05) who Enter this Narrow Gate Annually 1068 (FY 2014) 50,700 20-30 11 420

% of Children (0-5) in Hawai‘i who Enter this Narrow Gate 1.2% 56.3% .02% .01% .47%

3324 603 65

3.7% .67% .07%

Not available

Not available

Some of the Divisions/Programs/Offices assess or evaluate children, but in terms of screening children for behavioral health, only five Divisions/Programs/Offices screen children, and these are conducted either

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by contractors or by staff [as noted]: Division/Program/Office

Group Conducting Screening

Number of Children [0-5] Screened Annually at this Narrow gate

Child Welfare Services Family Court, 1st Circuit Home Visiting Unit

Contractors Staff Contractors

Med-Quest (Medicaid) West Hawai‘i Community Health Center

Contractors Staff

Not available 20-30 Only parents are screened for risk factors 41,700 26

% of Children (0-5) in Hawai‘i who are Screened at this Narrow Gate Not available .02% --46.3% .03%

Analysis of the survey data revealed that there are a number of opportunities for identifying behavioral health risk in children across multiple agencies and departments. Child welfare services (CWS) has access to all children entering the system as well as children who remain in the custody of their families but under CWS supervision. The system relies heavily on primary care providers to conduct screening and referral, but there is no tracking system that ensures that this is happening.

The courts have protocols for screening all children, but this “rarely” occurs.

Although capable of screening, it appears that the federally qualified Community Health Centers screen very few children, and CAMHD and Head Start, with access to numerous children, do not conduct screenings. It also is obvious that the public is not aware of access to screening. For example, the Department of Education’s “Operation Search” had only 11 families call in to request screening for their children ages 3 to 5 years in the 2014-2015 school year.

For the two programs in which staff members conduct screening of children, there was a range of professional qualifications required. One program [Family Court] requires a Master’s Degree in Psychology or coursework completed for a PsyD degree. West Hawai‘i FQHC utilizes front desk staff who had a brief training in administering the questionnaires. For the programs that use contractors, Med-Quest and CWS rely on medical professionals [i.e., physicians, APRNs, and PAs]. Follow up protocols and procedures for those children who screen positive are unclear and appear to be fairly inconsistent.

The survey also demonstrated opportunities for developing protocols across systems. Multiple different screening instruments are used across the various departments and programs, including some that actually are designed for assessment rather than screening. The mix of screening instruments allows for identification of different markers across the population and makes it difficult

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to develop any cohesive idea of what behavioral health difficulties children in Hawai‘i are facing.

Training on screening is sorely needed. This training should include how to provide guidance on decision-making as to the next best step for the child and how to provide earliest intervention within the primary screening site. The training programs should be followed up with quality assurance activities.

There is very little active review in any programs to assess the consistency and quality of screening activities.

The survey regarding screening also revealed that there are strong early intervention services available in the state, primarily through the Department of Health’s Early Intervention programs for children birth to 3 years and the Department of Education’s prekindergarten special education services for children 3 to 5 years.

No matter what narrow gate they may enter, tracking behavioral health data for children is problematic. Programs are not aware if any prior screening occurred. Some programs, however, did have information systems that allowed them to track children internally within their department/program/division, such as Early Intervention, Home Visiting, DOE’s eCSSS system, CAMHD’s EHR system, and West Hawai‘i FQHC’s excel worksheet database. None of these tracking systems communicate with any other.

SMART System of Care Utilizing the data and information gathered through the planning process, the Leadership Team came to consensus around developing a SMART System of Care for children birth to 5 years throughout the state of Hawai‘i. As described previously in this document, the SMART System of Care is a coordinated and integrated system of health and behavioral health care for all children. It is grounded in13: • Screening • decision Making • Assessment • Referral • Treatment Planning is dedicated to a shared vision for the children’s behavioral health system of care: Hawai'i's children will be born healthy and will thrive physically, socially, and emotionally, supported by safe, nurturing families and an integrated system of universal behavioral health screening, assessment, referral and treatment that will promote the ultimate well-being of all children and their success in school.

The central aim of the of SMART System of Care is to identify all children who are at risk for medical, mental health, emotional, developmental or learning

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problems and ensure they and their families receive the appropriate level of assessment and treatment they need for the children to succeed in school and in life. The overall structure of the system can be defined through a four-tiered pyramid based on a response to intervention model: Tier 4 2-4% of children

Tier 3 6-8% of children Tier 2 10% of children Tier 1 80% of children

Tier 1 – All children receive Tier 1 interventions through universal screening of pregnant women and screening of all children. This tier is grounded in universal public and professional education that addresses children’s behavioral health, including reducing the stigma associated with mental health difficulties. Classroom teachers, health care providers, and others who interact with children and families provide earliest interventions and supports.

Tier 2 – Based on universal developmental and behavioral health screening, children identified as “at risk” via a positive screen and for whom Tier 1 interventions are not supportive enough receive Tier II early intervention. These interventions, including family support and guidance, can occur in the medical offices, the classroom, or through IDEA services (Part C for children 0-3 years, Part B for children 3-5 years).

Tier 3 – Children who are not making adequate progress through Tier 2 interventions or children whose family environment cannot support positive behavioral and mental health development will move into Tier 3 interventions. Tier 3 interventions are grounded in targeted assessments and address areas of deficit through group interventions, parenting education and support, and school-based intensive instruction, specific to the child’s area(s) of need. Specialized clinical programs in the community, specialists in the specific area of deficit or risk, and the schools provide Tier 3 interventions.

Tier 4 – Children who are not making adequate progress through Tier 3 interventions or children with complex needs, including those whose family environment does not function in a way to promote healthy development, will receive Tier 4 interventions. Tier 4 interventions are grounded in a comprehensive assessment across all domains of child and family functioning that results in a wide-ranging and comprehensive

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treatment plan that can guide interventions across multiple domains. The comprehensive assessments are conducted and the treatment plans are developed within a highly trained, multidisciplinary children’s neurodevelopmental health center. Therapy is provided through this center or through community-based providers with special, high quality expertise.

The following descriptions provide more detailed information for each tier and how children will move through the system of care.

Tier 1 Description All children receive Tier 1 interventions through universal screening of pregnant women and screening of all children birth to 5 years. This tier is grounded in universal public and professional education that addresses children’s behavioral health, including reducing the stigma associated with mental health difficulties. Classroom teachers, health care providers, and others who interact with children and families provide interventions and supports.

Goal 1A for Tier 1: Professionals and the general public will understand the importance and impact of behavioral health problems in children.

Outcomes: 1. Through a public health campaign, 75% of the general public will be able to communicate the importance and impact of behavioral health problems in children.

2. Through professional education, 75% of clinicians across a broad spectrum of disciplines will: a. Demonstrate a statistically significant increase in knowledge regarding the prevention of and interventions for children’s behavioral health problems. b. Be able to communicate the importance and impact of behavioral health problems in children.

Goal 1B for Tier 1: Women’s prenatal care providers and clinic personnel will effectively screen and identify all pregnant women at risk for alcohol, tobacco, and illicit drug use.

Outcomes: 1. 75% of women’s and children’s health care providers and clinic personnel in each of the islands will participate in the training and technical assistance activities of this initiative.

2. At the completion of training activities, 75% of participants will demonstrate a statistically significant increase in knowledge regarding alcohol, tobacco, and illicit drug use in pregnancy and its impact on the child.

Goal 1C for Tier 1: Pregnant women using alcohol, tobacco, and illicit drugs 19 | P a g e

will be identified in the prenatal care setting and receive an appropriate level of intervention.

Measurable objectives: 1. 90% of women enrolled in prenatal health care will be screened for alcohol, tobacco and illicit drug use.

2. 90% of women who have a positive screen for alcohol, tobacco, and illicit drug use will receive a brief intervention in the prenatal health care setting.

3. 90% of pregnant women who require further evaluation and treatment will receive a referral to an appropriate treatment program.

Goal ID for Tier 1: Children at risk for behavioral health problems will be identified in a variety of clinical, social service, and educational settings and receive an appropriate level of intervention.

Outcomes: 1. 90% of children enrolled in children’s health care, social service and educational services will be screened for risk of behavioral health problems.

2. 90% of children who have a positive screen for risk of behavioral health problems will receive site-based early intervention services.

3. 90% of children identified through early intervention services but who need further evaluation and intervention will be referred to Tier 2 services.

Funding Sources to Achieve this Goal Currently used sources of funding to cover these costs, including screening, workforce development, parent education, and advocacy:  Head Start [Federal funds distributed to non-profits in the state] (FY2015 federal grant to non-profits is $20,035,000, this includes all HS services, not just screenings)  Title V [Child Health] (Block grant for FY2015 is $2,144,047, this includes all activities)  Maternal Infant Early Childhood Home Visiting [MIECHV/ACA] (FY2015 $1,000,000 and an additional $8,430,783 of discretionary funds; there is also a state match)  Early Childhood Comprehensive Systems Grant [Federal grant through the Health Resources Services Administration (HRSA)] ($140,000)  Title IV-B [Child Welfare Service Branch, DHS] (FY2015 is $2,032,258, this includes all CWSB activities)  Aloha United Way’s Developmental Screening Programs (FY2015 $105,181)  Project LAUNCH [short term SAMHSA grant] Currently unused, or slightly used, but potential sources of funding to cover these costs, including screening, workforce development, parent education, and advocacy: 20 | P a g e

     

Title XIX, EPSDT ($119,757,247; there is an additional state match) Private Insurance payers Child Care Development Fund [CCDF] ($4,971,630, primarily pays for child care) Preschool Development Grant ($14,000,000 2015-2018) Early Head Start/Child Care Grant (FY2016 $1,400,000) Screening for and treating maternal depression through Title V Maternal Child Health Block Grant (MCHBG)

Activities that Contribute to this Goal  Public health campaign addressing children’s behavioral health risk and interventions  Professional education addressing children’s behavioral health risk and interventions  Screening pregnant women for substance/toxic exposure  Providing a brief intervention to pregnant women  Conducting behavioral health screenings on children birth to 5 years  Storing child-level data on screenings  Sharing data from screenings with referral resources  Training those conducting screenings  Convening workgroups to discuss screening policy  Educating families on conducting screenings Hawai‘i’s Progress on Meeting Goal Screening, brief intervention and treatment for pregnant women using alcohol, tobacco and illicit drugs The majority of federally funded Community Health Centers, some private practices, and a variety of public health and social service agencies are screening pregnant women for alcohol, tobacco and illicit drugs, providing a brief intervention on-site, and referring to treatment as needed.

Current data regarding substance use among the approximately 7,000 women who have been screened were presented previously in this document.

Conducting developmental screenings on children [before age 5] Statewide, the current estimated number of children screened is about 30%.

Screening typically is conducted by:  Primary Care Providers: pediatricians, pediatric specialists, family physicians, community health centers, general practice, internal medicine  Head Starts/Preschools/Child Care Providers/Home Visitors The tools commonly used [and the groups using them] are:

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   

Ages & Stages Questionnaire; Ages & Stages Questionnaire: Social Emotional [ASQ, ASQ-SE]: Home Visitors [DOH and DHS], Child Care/Preschool providers, Head Start Parents’ Evaluation of Developmental Status [PEDS]: Hawai‘i Pediatricians Rapid Assessment Instrument (RAI) for children 4-18 [CWSB, DHS] Child Behavioral Checklist (CBCL) for children 2-3 [CWSB, DHS]



In SFY2012, 72.2% of children eligible for EPSDT screenings were screened.



DHS administrative rules for child care (family child care and centerbased) have an Integration of Mental Health Concepts item, which requires that the provider regularly communicate with the parents/guardians about the child's development and that the provider be aware of community resources to help recognize and foster age appropriate behavioral development in children and share the information of community resources with the parents/guardians.

However, there is not a requirement that the provider conducts developmental screenings.

Storing child-level data on screenings There have been some attempts to store child-level data, but only in certain communities, both of which are located on Oahu.

Training those conducting screenings Numerous training opportunities occur that at times cover developmental screenings, including using ASQ and ASQ-SE. Some examples of these include:  Family Child Interaction Learning (FCIL) programs conduct own staff trainings or contact DOH for support  Family, Friend, and Neighbor (FFN) training through Learning to Grow (DHS, CCDF Quality dollars) funding  Hawai‘i Association for the Education of Young Children (HAEYC)’s annual conference  Hawai‘i Home Visiting Network  Head Start annual training  The Parent Line (this contract requires contractors to provide training of trainers on ASQ) Convening workgroups to discuss screening policy The following groups have been meeting in the past five years to discuss developmental screening policy: • Action Strategy: Team 3 (Governor’s Office) • American Academy of Pediatrics: Building Bridges • Child Mental Health Initiative (DOH)

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• • • • • • • •

Early Childhood Comprehensive Systems: Screening Management Team (DOH) Hawai‘i Child Welfare Services-Program Improvement Plan (PIP2) Steering Committee (DHS) Hawai‘i Wrap Services Project Coordinating Committee (DHS) Healthy Child Care Hawai‘i (DOH, UH) Hui Kupa`a Collective Impact (Governor’s Office) Maternal Child Health Workforce Development (DOH) Screening and Assessment Workgroup (CWSB, DHS) Title V Screening Work Group (DOH)

Next Steps 1. Increase the number of children screened:  Support pediatricians by helping problem solve some of the common barriers they identify: a lack of time to administer screens during health visits; inadequate compensation; lack of training in the use of specific tools; and lack of, or perceived lack of, assessment and treatment resources14.  Help EPSDT and private insurance plans in using the existing procedure code (CPT code 96110) for enhanced reimbursement to providers for using a validated tool to perform developmental screening.  Review the Medicaid state plan in terms of allowable locations for screenings, the qualifications of who can bill for screening children, what specific services are individually reimbursed by Medicaid, allowable frequency of screening reimbursement, and the amount paid for each service.

2. Align developmental screening policies:  Determine the state agency or entity that will be the decision maker for policy decisions. One department could then order and sell the kits and offers trainings to providers [currently this is being done by DOH for the newborn metabolic screenings with the hospitals]  Coordinate and possibly combine some of the workgroups that have been discussing developmental screening.  Collectively identify the valid screening tools that will be used statewide.  For those using the same tools, identify a consistent cut-off score used to determine when children need services.  Include all funding experts (EPSDT or private insurance payers) in the workgroups  Develop common protocols or policies for screening and administering the tool and referring children who are positive  Incorporate developmental monitoring into DHS child care licensing requirements.

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3. Support workforce development:  Advocate for the regular use of developmental screening tools in the care of pediatric patients be incorporated into training programs for medical residents, pediatric nurse practitioners, MORE  Developing a statewide training plan for selected tool[s], possibly working with CCDF training funds [DHS], supporting providers in conducting workshops on talking to families about it, and understanding what to do with results  Working with ASQ/Brookes and other publishers if identified to see if there is a way to develop a certification/license [like first aid]

Tier 2 Description Based on universal developmental and behavioral health screening, children identified as “at risk” via a positive screen and for whom Tier 1 interventions are not supportive enough receive Tier II early intervention.

These interventions, including family support and guidance, can occur in the medical offices, the classroom, or through IDEA services (Part C for children 0-3 years, Part B for children 3-5 years).

Goal for Tier 2: All children who need early intervention services will have access to appropriate services through a variety of public and private agencies.

Outcomes: 1. 90% of children identified as requiring Tier 2 assessment will receive an appropriate assessment.

2. 90% of children whose assessment indicates a need for early intervention services will receive appropriate services.

3. 90% of children who do not demonstrate progress in Tier 2 services will be referred to Tier 3 services.

Funding Sources to Achieve this Goal The primary source of funds currently being used to pay for the services within this tier come from the US Department of Education’s Individuals with Disabilities Education Act [IDEA]. Early Intervention (EI), Part C covers children up to the age of 3 ($2,148,926 FY15) and Special Education Preschool, Part B children aged 3 to 5 ($903,031; state match $257,701).

There is not a sliding scale in the state regulations for the EI program. There is a clause in the statute that says that if children are eligible for Part C, the private insurance companies do not have to pay for these services.

Activities that Contribute to this Goal  Appropriate and accurate interpretation of screening information  Referring children to early intervention with relevant data  Informing families/community about EI/SPED services  Training EI/SPED staff  Providing direct EI/SPED services to children 24 | P a g e



Receiving, storing, and sharing data on services provided with other providers

Hawai‘i’s Progress on Meeting Goal Appropriate and accurate interpretation of screening information The degree to which this is occurring cannot be determined.

Referring children to early intervention with relevant data  Early Intervention referrals primarily come from physicians.  The intake data system at DOH is being updated; currently it does not ask if Home Visitors refer children, even though they have been. So there may be more pathways that are being utilized to refer children, however there is not any data to verify this.  Each agency has a different cut-off for making referrals [even if though they mainly use the ASQ-SE].

Informing families/community about EI/SPED services  Hawai‘i’s Department of Health operates Hawai‘i Keiki Information Service System [H-KISS] for up to age 3 and The Parent Line for children 020.  Hawai‘i Department of Education’s Operation Search [ages 3-20].15  The Hilopa‘a Family to Family Health Information Center provides free information and assistance to families and professionals on referrals, technical assistance and training.16  The Parent Line Training EI/SPED staff In a recent State Systemic Improvement Plan (SSIP) Provider Survey17:  One in four staff report that they are not comfortable in understanding age-appropriate social-emotional skills for children [birth to age 6]  63% report waning more training on communicating about sensitive issues to the cultural stigma related to mental health services  Respondents wanted training on challenging behaviors [73%], socialemotional development [57%], evidenced based practices in socialemotional development [72%] In Hawai‘i, there is a need for more speech, language, and physical therapists.

One of the barriers that has been identified by DOH is the procedure that DHRD implements takes a long time approving positions, so there is a delay in hiring people.

Providing high quality, direct EI/SPED services to children Quality of Services Early Intervention

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Hawai‘i has a lower percentage of children with a substantial increased rate of growth compared to the nation in social-emotional development and knowledge and skills.18 About 3 in 10 children with military insurance and about 2 in 10 children with Medicaid [QUEST] did not achieve age-level functioning, compared to about 1 in 10 children with private insurance. 19 Almost 9 in 10 children eligible for EI services due to biological risk maintained or achieved age-level functioning. More children will developmental delays did not age-level functioning (22%). Almost 4 out of 10 children eligible due to biological risk and developmental delay were not functioning on par with their peers at exit from EI. 20 Special Education Preschool Of those children who entered the program below age expectations in each of the following outcome, the percent who substantially increased their rate of growth by the time they turned six years of age or exited the program in the outcome of21:  Positive social-emotional skills (96.5%)  Acquisition and use of knowledge and skills (97.6%)  Use of appropriate behaviors to meet their needs (95.1) The percent of children who were functioning within age expectations in each of the following outcomes by the time they turned six years of age or exited the program:  Positive social-emotional skills (51.2%)  Acquisition and use of knowledge and skills (51.1%)  Use of appropriate behaviors to meet their needs (60.0%) Service Delivery  Almost 4% of Hawai‘i’s infants and toddlers receive Part C, Early Intervention services22 and 4.9% receive services under Part B, Special Education Preschool23.  Early Intervention in Hawai‘i does not implement a medical model. They are a primary source provider through a coaching model. Typically, the therapists go into a child’s home for 25-30 hours per week.

Unfortunately, the parent sometimes views this service as “babysitting.”

19% of the children referred for EI are deemed ineligible.  

Children who receive EI services do so through private providers who have state contracts [85%] and through state provided services [15%].24 There is a lack of community sites to support serving children in natural environments when families do not want providers in their homes.

Transition from Part C to Part B Part C [operated by DOH] serves children up to age 3, and then they 26 | P a g e

transition to Part B [operated by DOE]. There are several mechanisms in place to encourage a smooth transition and continuation of services for children: An MOA/MOU is in the process of being finalized by the DOH and DOE. There is a STEPS State team and local STEPS teams, which bring together Part C and Part B. This worked successfully years ago in aligning policies, offering joint training, supporting families and children through transitions of care, but has faced challenges. The challenges identified: 

No DOE person who is solely responsible for 619. In the past DOE had this position, the current person has lots of other responsibilities.



619 Coordinators [Part B, DOE] are not meeting as a team anymore.



No longer are the Part C and Part B attending joint trainings.



DOE does not accept Part C evaluations

Receiving, storing, and sharing data on services provided with other providers Early Intervention uses two different data systems one which stores children’s social-emotional levels [as measured by the BDI-2] and another that stores the Child Outcomes Summary [COS] rating. Both of these systems are non-web-based. The COS ratings are entered into the Hawai‘i Early Intervention Data System (HEIDS) which is intended to “improve service delivery for children, assist providers in managing their programs, and provide Hawai‘i Part C administration with data for the purpose of assessing compliance with federal and state reporting requirements.” 25 Next steps 1. Increase access to appropriate early intervention services:  Assess availability of programs  Educate front line screeners as to programs available and how to make referrals  Educate families as to early intervention programs, their purpose, and their availability  Promote self-referral to early intervention programs.

2. Align early intervention eligibility guidelines and policies:  

Determine eligibility criteria and assess gaps in services that may exist due to these criteria Educate professionals and families as to the eligibility criteria for various early intervention programs 27 | P a g e

   

Expand, when possible, eligibility criteria beyond purely developmental or educational issues to include the broader range of behavioral health difficulties faced by young children Coordinate access efforts with work groups and organizations addressing universal screening Ensure payment pathways for early intervention services Require that all children birth to age 3 entering the foster care system be assessed thru IDEA Part C Early Intervention program.

3. Support workforce development  Educate early intervention professionals as to broader implications of behavioral health challenges beyond current organizational definitions  Developing a statewide training plan for families and early intervention specialists

Tier 3 Description Children who are not making adequate progress through Tier 2 interventions or children whose family environment cannot support positive behavioral and mental health development will receive Tier 3 interventions. Interventions are grounded in targeted assessments and address areas of deficit through group interventions, parenting education and support, and school-based intensive instruction, specific to the child’s area(s) of need. Specialized clinical programs in the community, specialists in the specific area of deficit or risk, and the schools provide Tier 3 interventions.

Goal for Tier 3: All children who need focused therapeutic services will have access to appropriate services through a variety of public and private agencies.

Outcomes: 1. 90% of children identified as requiring Tier 3 assessment will receive an appropriate assessment.

2. 90% of children whose assessment indicates a need for focused therapeutic services will receive appropriate services.

1. 90% of children who do not demonstrate progress in Tier 3 services will be referred to Tier 4 services.

Funding Sources to Achieve this Goal EPSDT should be the primary source to pay for funding of clinical services for children within this level. The required state match is 50%.

There are other sources of funding that support some Tier 3 efforts including: 

Enhanced Healthy Starts is a Home Visiting program with active Child Welfare Service Branch [CWSB] paid for by TANF funds [$2,800,000, annually].

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 

Title IV-B2 service categories for specific populations, primarily focused on neighbor islands and in rural communities. [SFY2013 $946,084].

Hawai‘i has chosen for its Title IV-E waiver to address using data to inform practice and re-entry into foster care.

Currently unused but potential sources of funding to cover these costs, include:  Title IV-E funding can be a source for training of professionals and training support of foster, adoptive and biologic parents.  Title XIX federal funds provides an opportunity to enhance outreach and support services for Medicaid eligible pregnant and parenting women.  Local foundations.  Title XIX to pay for public health nurses to provide care coordination.  Finance early childhood mental health consultation with CCDF funds [thru quality dollars’, by transferring TANF funds to CCDF or the Social Services Block Grant [SSBG], with Medicaid/EPSDT [for individual children].

Activities that Contribute to this Goal Ways that activities/projects/programs support children’s Tier 3 targeted assessments and interventions before age 5:  Conducting a targeted assessment of child and family functioning that results in a treatment plan that can guide interventions targeted at the child’s specific deficits and challenges.  Receiving, storing, and sharing data on services provided with other providers  A referral system will ensure that all children will have access and be linked to the appropriate community based services indicated in the treatment plan  Providing therapy through community-based providers with special, high quality expertise Hawai‘i’s Progress on Meeting Goal Conducting a targeted assessment of child and family functioning that results in a treatment plan that can guide interventions targeted at the child’s specific deficits and challenges.  Statewide, there is no central definition of what an assessment means.

Therefore, many groups state they are assessing children, but these assessments tend to be focused on the expertise of the providers.

Assessment is limited to the knowledge and capabilities of the workforce.  The group that appears to be consistently providing targeted assessment for children is the federally qualified health care centers [FQHCs]. The FQHCs only serve children who are Medicaid eligible.  There are a few providers that assess children, but their numbers are quite small [12-75 children] and tend to be focused on specific populations, such as families experiencing domestic violence and/or

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homelessness.

Some of the programs that conduct assessments reported having waiting lists for children needing to be assessed.

Receiving, storing, and sharing data on services provided through other providers.

DHS has continued to rely on and make minor changes to its automated computer data system, Child Protective Service System (CPSS). The system is used for readily identifying the status, demographic characteristics, location, and placement goals of every child who is in foster care. In addition, they have continued to use the SHAKA (State of Hawai‘i Automated Keiki Assistance) system for certain functions, such as the 48-hour Tracker to monitor timely response to child abuse and neglect intakes, the National Youth in Transition Database, worker visit surveys, tracking completion of transition plans for youth who will be aging out of foster care, applications for higher education allowances and education and training vouchers, etc. There have been work groups and agreements to support CPSS and SHAKA in working together to develop an effective and user-friendly way to track worker visits with children.

A referral system will ensure that all children will have access and be linked to the appropriate community based services indicated in the treatment plan.  Referrals are happening, however there is no system to track these children to ensure that they receive the appropriate and defined treatment identified in their assessment plan. One provider commented, “Our challenge is that we have no tracking, nor metrics to provide details on this population.”  Again, the group that reports that they have a system in place is the FQHCs.  Several non-profits report that they have internal systems to track if families follow-up on their treatment plans. These tend to be more informal and based on the relationship the program staff have with the families.

Providing therapy through community-based providers with special, high quality expertise.  Most programs that provide treatment are not using evidence-based models.  A limited number of providers are using evidence based treatment approaches, but in many cases they are using them with populations for which the program was never intended. Less than 25% of the programs surveyed offered high-quality treatment, and these programs only serve 739 children collectively.  The Child and Adolescent Mental Health Division’s (CAMDH) population’s age distribution is heavily skewed, with the largest proportion of youth served being older, average age 14.1 and the

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Developmental Disabilities Division (DDD) only providers services to adults.

Next Steps 1. Expand payment options  Support adequate provider payment rates through using a rate methodology that reflects actual market rates to establish service reimbursement rates.  

Provide support so programs can navigate rules so they can access EPSDT to pay for services.

The EPSDT required match comes from State funds that are typically allocated to where the services originate [mostly DHS and DOH]. DOE is a potential source for additional matched funds.

2. Support DHS/DOH in reviewing and possibly expanding their contract requirements so that:  Contracted providers have financial incentives and/or sanctions based on quality of care indicators, and specified outcomes at the system, program, and child and family levels.  There are funds to carry out contract monitoring activities and reporting.

3. Unify referral process/system  Develop web-based centralized referral system 4. Enhance quality of services  Train the workforce to be certified on various interventions/therapies.

This includes ongoing quality assurance evaluations.

Tier 4 Description Children who are not making adequate progress through Tier 3 interventions or children with complex needs, including those whose family environment does not function in a way to promote healthy development, will receive Tier 4 interventions. Tier 4 interventions are grounded in a comprehensive assessment across all domains of child and family functioning that results in a wide-ranging and comprehensive treatment plan that can guide interventions across multiple domains. The comprehensive assessments are conducted and the treatment plans are developed within a highly trained, multidisciplinary children’s neurodevelopmental health center. Therapy is provided through this center or through community-based providers with special, high quality expertise.

Goal for Tier 4: All children with complex needs who require comprehensive neurodevelopmental assessment and therapeutic services will have access to appropriate services through a central children’s behavioral health center.

Outcomes: 31 | P a g e

1. 90% of children identified as requiring Tier 4 comprehensive neurodevelopmental assessment will receive an appropriate assessment.

2. 90% of children whose assessment indicates a need for comprehensive neurodevelopmental therapeutic services will receive appropriate services.

Funding Sources to Achieve this Goal Currently, there is not an agency or organization operating at this Tier. Once one is identified, the funds needed to operate these services will include:  Some of the organization or agency’s current operating funds for indirect or overhead costs.  EPSDT funds, which would require the agency or organization has a system for billing Medicaid.  Private insurance payers, which also requires a system for billing.  Foundation support.

It is critical to remember that this model of care is only sustainable if multiple sources of revenue are committed to its success. Moreover, the sources of revenue must make an enduring commitment to avoid instability.

Activities that Contribute to this Goal Ways that activities/projects/programs support children’s Tier 4 comprehensive neurodevelopmental assessments and interventions before age 5:  Conducting comprehensive assessments across all domains of child and family functioning that results in a wide-ranging and comprehensive treatment plan that can guide interventions across multiple domains.

These assessments include Pediatricians, Public Health Nurses, Infant Mental Health specialists and other trained professionals for health and behavioral health problems that will result in a long-term treatment plan.  Receiving, storing, and sharing data on services provided with other providers  Providing therapy in a centralized location or in collaboration with community-based providers with special, high quality expertise  Training a multidisciplinary team to implement high-quality behavioral health services Hawai‘i’s Progress on Meeting Goal Conducting comprehensive assessments across all domains of child and family functioning that results in a wide-ranging and comprehensive treatment plan that can guide interventions across multiple domains for children who require this level of care. These assessments include Pediatricians, Public Health Nurses, Infant Mental Health specialists and other trained professionals 32 | P a g e

for health and behavioral health problems that will result in a long-term treatment plan.  There is no formal effort to identify and monitor high-risk children across all aspects of the Hawai‘i Island community.  There is no single site responsible for ensuring comprehensive assessment for these children, although a thorough assessment must guide effective treatment planning.

Receiving, storing, and sharing data on services provided with other providers This is not happening in a systematic or uniform way.

Providing therapy in a centralized location or in collaboration with communitybased providers with special, high quality expertise  Service delivery, especially treatment, is based on funding streams, so that children at risk for health and behavioral health problems are referred to a variety of providers through specific programs that address a single need.  Although collaborative efforts have been attempted in the past, there is little communication among caseworkers in the various agencies.  The school system is marginalized in the overall effort to bring mental health services to young children. This is not seen as a core responsibility of the schools’ special education programs except in rare instances.  Children in families that suffer from substance abuse and domestic violence live on the periphery of social, medical, and educational settings so that systems of care never reach them until their complete failure brings them to the attention of the school system, the juvenile justice system, or child protective services.

Training a multidisciplinary team to implement high-quality behavioral health services  To achieve this goal, training must address clinical, administrative, and procedural approaches to comprehensive and integrated assessment and treatment.  There is no recognized resource in Hawai‘i for providing this advanced training.

Next Steps Identify an agency or agencies that will create a children’s behavioral health center for Hawai‘i. This center will provide a place where all aspects of a child’s behavioral health, including emotional, developmental, and biological health, can be assessed by a multi-disciplinary team and then nurtured to support the child’s ability to function in every day life, his or her concept of self, and the ability to relate to others.

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The first six months will be dedicated to start up, with a focus on administrative organization, identifying and moving into the center offices, purchasing of supplies and equipment, hiring, and finalizing clinical protocols and service plans. In addition, as part of the start-up, we will develop the system for billing Medicaid and other third party payers for services, including private insurance.

The second six months will be a pilot phase in which children and families will be seen for services at the center. Protocols will be tested to ensure appropriate application to Hawai‘i’s unique populations are developed, data management will be tested, and insurance and third party payer billing procedures will be tested and finalized.

During the first year of operations, training of local professionals will begin.

Over time, local professionals will assume responsibility for the delivery of assessment and treatment services.

Advancing the Plan: 2016 As we move into the next year, the “next step” specific strategies presented for each of the four tiers will guide the next phase of work. Overall, the focus will be on implementing screening and earliest interventions among early adapter sites, enhancing the quality of services provided by Tier 3 community programs, development of the Tier 4 Children’s Behavioral Health Center, and linking the participating systems.

1. There are several groups currently providing some form of screening of children at the primary contact level. We need to identify specific groups who will serve as “early adapters” and develop appropriate Memoranda of Understanding and data sharing agreements with these groups. One component of the “early adapter” program will be recruiting physicians and other health care personnel to participate in the program. Training to upgrade the quality and consistency of screening and earliest intervention services will be necessary.

2. Training and professional development is an acute need. It has been the general consensus of the Leadership Team that training needs lie at the heart of systems improvement. However, discussions of training have been nebulous and indirect. When one examines the Tier 1 surveys, it can be seen that quite a bit of “training” already occurs. However, it does not appear that it always is of the highest quality, and much of it is peer to peer, which lacks in quality control. In the early part of the year it is recommended that the HCF team:  determine precise training needs of each department and division, most likely via survey, interviews;  determine precise training needs of private agencies throughout the state, especially those agencies that would provide Tier 3 services;  decide what aspects of training should be supported by the foundation and which aspects should be left to the departments and 34 | P a g e

private agencies; develop a training of trainer strategy for any training we will conduct/support so as to make the impact of the training sustainable;  develop a training schedule, including appropriate faculty.

This will position us in the latter half of the year to begin training in an organized and meaningful way that is linked to roll out of the system.

3. The administrative and clinical development of the Tier 4 Children’s Behavioral Health Center will necessarily be a long and slow process that should be initiated in the early part of the year. This should include site visits to mainland programs that have been developed through the SMART system strategy. Other members of the leadership team could well benefit from the exposure, also.

4. Evaluation, both process and outcome, will be the factor that drives sustainability and ongoing funding of the system. Good evaluators want to be involved in the early stages of planning so as to understand the underpinnings of the program and expectations for outcomes. Thus, we should bring an evaluation team in relatively soon and start laying out how we want to document and track change, including cost/benefit analyses.

5. A communication strategy needs to be developed in order to stay ahead of public expectations. This strategy will need to include action steps with target audience(s), a timeline, and the development of appropriate on-line and hard copy print materials for distribution. We might consider the development of a web site dedicated to the SMART system of care, which could be used to communicate with professionals as well as the public. 

U.S. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

1

Friedman, R., Katz-Leavy, J., Manderscheid, R., & Sondheimer, D. (1998).

Prevalence of serious emotional disturbance in children and adolescents. An update. In R. W. Manderscheid & M. J. Sonnenschein (Eds.), Mental health, United States, 1998 (HHS Publication No. SMA99-3285) (pp. 100-112).

Washington, DC: U.S. Government Printing Office.

Perou, R. (2013, May). Mental health surveillance among children: United States, 2005-2011. Center for Disease Control and Prevention Morbidity and Mortality Weekly Report (MMWR).

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Huang, L., Stroul, B., Friedman, R., Mrazek, P., Friesen, B., Pires, S., & Mayberg, S. (2005). Transforming mental health care for children and their families. American Psychologist, 60(6), 615-627.

2

Clark, H. B., Deschenes, N., Sieler, D., Green, M. E., White, G., & Sondheimer, D. L. (2008). Services for youth in in transition to adulthood systems of care. In B. A. Stroul & G. M. Blau (Eds.), The systems of care handbook: Transforming mental health services for children, youth, and families (pp. 517-543). Baltimore, MD: Paul H. Brookes.

Cocozza, J. J., Skowyra, K. R., Burrell, J. L., Dollard, T. P., & Scales, J. P. (2008) Services for youth in the juvenile system in systems of care. In B. A. Stroul & G. M. Blau (Eds.), The systems of care handbook: Transforming mental health services for children, youth, and families (pp. 573-593). Baltimore, MD: Paul H. Brookes.

Epstein, M. H., Nelson, J. R., Trout, A. L., & Mooney, P. (2005). Achievement and emotional disturbance: Academic status and intervention research. In M. H. Epstein, K. Kutash, & A. J. Duchnowski (Eds.), Outcomes for children and youth with emotional and behavioral disorders and their families: Programs and evaluation best practices (2nd ed., pp. 451-477). Austin, TX: PRO-ED. National alliance on Mental Illness. (2010, July). Facts on children’s mental health in America. Retrieved on May 31, 2015: http://www2.nami.org/Template.cfm?Section=federal_and_state_policy_legis lation&template=/ContentManagement/ContentDisplay.cfm&ContentID=4380 4 Pullmann, M. D., Kerbs, J., Koroloff, N., Veach-White, E., Gaylor, R., & Sieler, D. (2006). Juvenile offenders with mental health needs: Reducing recidivism using wraparound. Crime and Delinquency, 52(3), 375-397.

Wagner, M., & Cameto, R. (2004). The characteristics, experiences, and outcomes of youth with emotional disturbances. NLTS2 Data Brief, 3(2).

Retrieved on May 31, 2015: http://www.ncset.org/publications/viewdesc.asp?id=1687 These cost estimates are based on research that analyzes cost savings when systems of care are implemented nationally and within sates and communities. Hawaii-specific data are not available.

3

Stroul, B., Pires, S., Boyce, S., Krivelyova, A., & Walrath, C., (2014). Return on investment in systems of care for children with behavioral health challenges.

Washington, DC: Georgetown University Center for Child and Human Development, National Technical Assistance Center for Children’s Mental Health.

4

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Their analysis was based on data obtained from: Agency for Healthcare Research and Quality. (2013). Emergency room services: Mean and median expenses per person with expense and distribution of expenses by source of payment: United States, 2009. Medical Expenditure Panel Survey household component data.

Stroul, B., Pires, S., Boyce, S., Krivelyova, A., & Walrath, C., (2014). Return on investment in systems of care for children with behavioral health challenges.

Washington, DC: Georgetown University Center for Child and Human Development, National Technical Assistance Center for Children’s Mental Health.

5

National Center on Addiction and Substance Abuse (CASA) at Columbia University. (2004). Criminal neglect: Substance abuse, juvenile justice and the children left behind. New York: Author.

6

Cornman, S. Q. (2013) Revenues and expenditures for public elementary and secondary education: School year 2010-11 (Fiscal Year 2011) (NCES 2013-342).

Washington, DC: U. S. Department of Education, Institute of Education Sciences, National Center for Education Statistics.

7

Sum, A., Khatiwada, I., & McLaughlin, J. (2009). The consequences of dropping out of high school: joblessness and jailing for high school dropouts and the high cost for taxpayers (Paper 23). Boston, MA: Northeastern University, Center for Labor Market Studies.

8

Carnevale, A. P., Rose, S. J., & Cheah, B. (2011). The college payoff: Education, occupations, lifetime earnings. Washington, DC: Georgetown University, Center on Education and the Workforce.

National Center on Addiction and Substance Abuse (CASA) at Columbia University. (2004). Criminal neglect: Substance abuse, juvenile justice and the children left behind. New York: Author.

9

Texas Department of State Health Services. (2011). Coordinated funding for children with serious emotional disturbance: Current funding, services and recommendations. Austin, TX: Texas Mental Health Transformation Working Group, Children and Adolescent Workgroup, Children’s Coordinated Funding Committee.

10

Gould, M. (2000). Mental health early intervention program for young children cost of failure study. Denver, CO: Colorado Department of Human Services.

11

Heilbrunn, J.Z. (2010). The cost of services revisited: Kid Connects mental health consultation as a cost savings investment strategy. Denver, CO: Colorado Department of Human Services.

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Family Child Interaction Learning (FCIL) programs delivery model involves parent/adult family member participation and child learning time. The programs require that the adults attend the program with the child.

12

McGourty, R. & Chasnoff, I. (2003). Power Beyond Measure. Chicago: NTI Upstream, 2003.

13

Sices, L., Feudtner, C., McLaughlin, J., Drotar, D., &Williams, M. (2004).

How do primary care physicians manage children with possible developmental delays? A national survey with an experimental design.

Pediatrics, 113(2):274-82.

14

To view the Operation Search brochure go to: http://www.hawaiipublicschools.org/DOE%20Forms/Special%20Education/ Operation_Search.pdf 15

For more information about Hilopaa visit: http://www.hilopaa.org/Pages/default.aspx 16

Hawaii Department of Health (April 1, 2015). Hawaii Part C FFY 2013 SSP/APR indicator 11: State systematic improvement plan (SSIP), phase 1.

Retrieved on 6/22/2015: http://health.hawaii.gov/eis/files/2013/05/HawaiiPartCSSIP-PhaseIApril2015.pdf 17

Hawaii Department of Health (June 2014). Part C early intervention, state systemic improvement plan: Supporting infants and toddlers social emotional development. Retrieved on 6/22/2015: http://health.hawaii.gov/eis/files/2013/05/SSIPBrief-June2014.pdf 18

Hawaii Department of Health (April 1, 2015). Hawaii Part C FFY 2013 SSP/APR indicator 11: State systematic improvement plan (SSIP), phase 1.

Retrieved on 6/22/2015: http://health.hawaii.gov/eis/files/2013/05/HawaiiPartCSSIP-PhaseIApril2015.pdf 19

20

Ibid.

These are preschool outcomes for FFY 2012. They are a state-selected data source. Sampling of children for assessment is allowed. Sample must yield valid and reliable data and must be representative of the population sampled.

Retrieved on 6/22/2015: http://www2.ed.gov/fund/data/report/idea/partbspap/2014/hi-accstatedatadisplay-12-13.pdf 21

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Early Intervention services offered include: Assistive Technology; Audiology; Care Coordination; Family Support/education; Health; Nursing; Nutrition; Occupational therapy; Parent-to-parent support; Physical therapy; Psychological support; Speech and language therapy; Social work (counseling); Specialized teaching; Transportation; and Vision.

22

For 2012-2013 SY, retrieved on 6/22/2015: http://www2.ed.gov/fund/data/report/idea/partbspap/2014/hi-accstatedatadisplay-12-13.pdf 23

The private service providers include: Easter Seals; IMUA Family Services; Ikaika Infant Toddler Development; Kau Child Development Program; Kona Child Development Program; Waianae Child Development Program; and North Hawaii Child Development Program.

24

Hawaii Department of Health (April 1, 2015). Hawaii Part C FFY 2013 SSP/APR indicator 11: State systematic improvement plan (SSIP), phase 1.

Retrieved on 6/22/2015: http://health.hawaii.gov/eis/files/2013/05/HawaiiPartCSSIP-PhaseIApril2015.pdf 25

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