Advances in Community Mental Health Treatment

Presented By:

Chris Morano Ph.D., Wraparound Milwaukee

What is Wraparound Milwaukee

A system of care organized to provide comprehensive services and supports to children and adolescents with serious emotional and mental health needs and their families

It is organized as a special managed care entity publically operated by Milwaukee County Behavioral Health Division under the 1915a provisions of the Social Security Act, which allows it to function as a type of HMO for a distinct Medicaid population within a specific geographical area (Milwaukee County)

Current enrollment is approximately 900 youth/families with 1400 families served annually

Specific Populations Wraparound Milwaukee Serves

Youth with a DSM-IV diagnosis With a more chronic condition likely to require

services for a year or more Currently or previously served across two or more

child serving systems i.e. Child Welfare, Juvenile Justice, Mental Health, special education

At imminent risk of placement in a : Residential treatment center Psychiatric hospital Juvenile correctional facility

Programs Operated by Wraparound Milwaukee

Mobile Urgent Treatment Team – crisis intervention services in Milwaukee County including dedicated teams with Child Welfare

Regular Wraparound – court-involved youth (600 youth) FOCUS – Corrections Alternative(Collaboration with

DCS/WM/St. Charles Re-Entry – youth with SED transitioning from DOC

( Collaboration with DOC and DCS) Healthy Transitions (Project O’YEAH) – 16 ½ to 24

youth/young adults transitioning to adulthood REACH – Wraparound Program for voluntary referrals (230) FISS – diversion from Child Welfare for status offenders ( 60

youth/families)

Characteristics of Our Population 72% Boys 71% African American, 17% Caucasian, 9% Hispanic Average Age 14 Status at enrollment in Wraparound Milwaukee

46% Delinquent 20% CHIPS 6% JIPS 28% None (voluntary REACH families)

Top Diagnosis: Conduct Disorder ADHD Depression/Mood AODA Learning Disorder Psychotic

Daily Youth Served in 2010- Delinquency order

Targeted Monitoring

Program(n=105)

Systems of Care Integration Model

“Wraparound Milwaukee”(n=430)

State Juvenile Corrections

(n=190)

Diversion(n=200)

Daily Average Youth Under DCSD/DOC ~ 2040

Pending or Community Probation

Philosophy of Care and Approach to Delivery

Care and Services to SED Youth/Families

Strength-based Highly individualized to meet specific needs of child

and family Comprehensive – We provide whatever services are

needed and “wrap” around family’s needs Family directed using child and family teams Community-based – emphasis is on treating child in

community while maintaining community safety Collaboration across systems – develop a single care

plan Culturally competent We don’t easily Give-up on any child

Components of Wraparound Milwaukee Program

Screening and Assessment Care Coordinator Mobile Crisis Family Advocacy Provider Network/Comprehensive Benefit Plan Clinical Oversight Quality Assurance IT/Program Evaluation Fiscal Management

How We Pool Funds

CHILD WELFAREFunds thru Case Rate

(Budget for InstitutionalCare for Chips Children)

JUVENILE JUSTICE(Funds Budgeted for

Residential Treatment and Juvenile Corrections Placements)

MEDICAID CAPITATION(1843 per Month per Enrollee)

MENTAL HEALTH•CRISIS BILLING•BLOCK GRANT•HMO COMMERCIAL INSUR

WRAPAROUND MILWAUKEECARE MANAGEMENT ORGANIZATION

(CMO)46.5 M

CHILDAND FAMILY

TEAM

PLANOF

CARE

10.0M 10.0M 19.5M 7.0 M

CARECOORDINATION PROVIDER NETWORK

210 Providers

80 Services

Wraparound Milwaukee’s Comprehensive

Service ArrayBehavioral & Clinical Services

– Crisis intervention• Individual therapy• Intensive in-home therapy• Evaluation• Substance abuse therapy • Medication management• Day treatment

Placement Services• Acute hospitalization• Foster home and treatment foster home• Group home care• Residential treatment• Crisis/residential, group, Level 4 FC• Supported independent living

Other Supportive• Camps• After school and Suspension

accountability• Transportation• Interpretive services• Equine/animal therapy• Consultation with other professionals

Supportive Services• Mentors, tutors• Crisis 1:1 stabilizer• Parent/family aide• Life coach – independent living• Employment preparation and placement• Job – internship

Respite• Crisis/planned respite• Residential respite

Service Coordination• Care Coordination

Discretionary• Clothing• Food/groceries• Housing assistance• Child care• Furniture, appliances• YMCA membership• Educational expenses

Outcomes for Wraparound Milwaukee

Financial – average cost per month: Wraparound Milwaukee is $3700 $9000 in DOC, over $9000 in RCCCY/month and over $10,000 7

days psychiatric hospital Programmatic – Milwaukee County population in RCCCY dropped

from 375 to 90 youth; drop in DOC population resulting in closure of two state facilities, reduction in psychiatric inpatient beds from over 250 to 50 beds

Clinical – improved functioning based on CBCL (Achenbach) Recidivism – most recent study of 669 delinquent youth enrolled in

Wraparound Milwaukee for a period of 15 months showed a 15.2% rate of reoffending. Among 210 “high risk youth” i.e. juvenile sex offenders, etc. the rate was even lower at 6.7%

Child Permanency – 75% of youth were in permanent setting with parent, relative, adoptive resource or subsidized guardianship

State Corrections

DOC Commitments

203

251

213 206

152

0

50

100

150

200

250

300

2006 2007 2008 2009 2010

Year

# D

OC

Co

mm

itm

ents

DOCCommitments

Is Wraparound Milwaukee an Evidence-Based Practice?

There are at least 10 studies currently supporting Wraparound as a EBP (National Wraparound Initiative NWI – lists on web-site)

We believe in Evidence Informed Approaches versus EBP’s

We don’t buy off the shelf programs ie. MST, etec We look at innovative approaches and “best practices” Adapt to our community circumstances and characteristics of

our population We measure overall impact on our youth/families through

established outcomes measures Market forces usually drive families to utilize providers and

services who are more innovative, get better outcomes and provide a better quality service

MUTT Team

•Crisis Intervention for all youth •Crisis group home/beds, inpatient gatekeeping•2 Clinical Psychologists, 20 Social Workers, Psychiatric Nurse, consulting Psychiatrist

•MUTT FF, MUTT TFC, •Crisis stabilizers•Outcomes•HFS 34

Trauma Informed Crisis Intervention…

• Based on Trauma Informed Care (Perry, 2009)

• Effects of trauma, neglect also seen when emotions high

• Neurosequential Therapeutic Assessment and response

Therefore…Neurosequential Therapeutic Response

•Inconsistent/absent/abusive early relationships = distressed, anxious, destructive youth who…

• ..live limbically in primitive part of brain•Move from self-regulation- relational- cortical/cognitive/verbal strategies

Therefore, therapy with traumatized,

complex needs/disorganized youth…

• In early stages = aimed at primitive part of brain = soothing, reorganizing

• Music, movement, massage, balance..

• NOT at the higher level functions, like speech – they’re not “ready”

“Therapy is two people in a room, one of whom is more anxious than the other”

..it’s immensely difficult to do..

• Crises traumatize staff, and, yes, in the immediate moment..

• Easy to lose it out there• > Brain hijacking

• = 3 Types of people……

So, just like managing a toddler’s TT…

• These kids have power, and are terrified by it, especially if you are.

• Undereact to everything

• Act “As if..”

• Be nurturing, repetitive, calm, and attentive to non-verbals!

Ethical and Boundary Challenges in the Community

•The good

•The bad

•The enticing….

Normalizing…

• Temper tantrums• Disagreeability• Defiance, anger• Need for immediate

gratification• Laziness, avoidance, etc.• Likes things you don’t

like (eg., music)• Even thoughts of death,

suicide

The Challenges of Family/consumer choice..

•Wraparound core value

•Italy and the neighborhood

The Ethics of…

• Diagnosis• Medication

The Ethics of Solutions..What helps???

• 2005 Milwaukee study

• APA 2006 Report• SAMHSA Findings

Favor Systems of Care• DC Interagency Forum +

Milwaukee Data = • Serious crime way down• Drinking, smoking, teen

pregnancy down

So…• …what’s next?