Community-Based Alternative to Psychiatric Residential Treatment Facilities Early

Community-Based Alternative to Psychiatric Residential Treatment Facilities: Early Evidence of Mississippi's MYPAC Program Effect For American Public Health Association (APHA) Annual Conference Philadelphia, Nov 8, 2009 Presenter: Ying Wang, Ph. D, IMPAQ International (IMPAQ) Co-authors: Kristi R. Plotner, LCSW, Mississippi Mental Health Programs; Oswaldo Urdapilleta, Ph. D, IMPAQ; Bonlitha Windham, LMFT, Mississippi Mental Health Programs; and Lacinda Jaynes, Mississippi Mental Health Programs SPONSOR: Centers for Medicare & Medicaid Services (CMS)

Presenter Disclosure Presenter: Ying Wang The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose 2

General Background • New Freedom Initiative (NFI) to remove barriers to community living for people with disabilities • The New Freedom Commission on Mental Health (the Commission), created on April 29, 2002, and its final report, Achieving the Promise: Transforming Mental Health. Care in America (July 26, 2003) • Section 6063 of the Deficit Reduction Act (DRA) of 2005 (P. L. 109 -171) • Congress-mandated demonstration grant program for Community-based Alternatives (CBA) to Psychiatric Residential Treatment Facilities (PRTF) 3

Background - Demonstration • The demonstration allows up to 10 States (as defined for purposes of title XIX of the Social Security Act) to test the cost effectiveness of providing coverage for home and community based service alternatives for children enrolled in the Medicaid program • A 1915(c) waiver demonstration • Total grant award by the Act: 217 millions • Nine states were awarded: MS, VA, KS, MT, SC, IN, AK, MD, and GA • Waiver program started in FFY 2008 • One million is reserved for national evaluation, mandated by the Congress 4

Background – Evaluation • Purpose of the Demonstration national evaluation is to: – test the effectiveness of the program in improving or maintaining a child’s functional level; – test the cost effectiveness of providing coverage of home and community based service alternatives to psychiatric residential treatment for children enrolled in the Medicaid program under of title XIX of such Act, as they compare to the cost of care in a residential program; and – maintain budget neutrality (1915 c cost neutrality) so that aggregate payments under the Demonstration do not exceed the costs estimated to have been incurred had the Demonstration not been in place. • Each Grantee conducts its own local evaluation 5

Background – Evaluation functional Outcomes of interest: – Community living – School functioning – Juvenile Justice – Alcohol and drug use – Mental health – Social support – Family functioning 6

National Evaluation Approach • To provide: – clear answers to the primary research questions at both State and National Level – useful information for those interested in developing similar programs in the future • Strategy – – Multi-site evaluations (9 states) Tiered-evaluation approach for core outcomes • • State-level individual outcome change analysis Cross-site individual outcome change analysis 7

National Evaluation Data Collection • Minimum Data Set (MDS) Collection – Core elements – Common outcome measures – Standardized functional outcome assessments • Children and Adolescent Needs and Strengths (CANS) • Child & Adolescent Functional Assessment Scale (CAFAS) • Child Behavioral Checklist (CBCL) – Services data – Fidelity measurements (WFI) – Satisfaction (YSS/YSSF) • Qualitative data on program implementation – Qualitative monitoring guide – Implementation status report 8

Mississippi Demonstration Program Mississippi Youth Programs Around the Clock 9

MYPAC Program - History • Mississippi Youth Programs Around the Clock (MYPAC) • Grant awarded on December 19, 2006 • Award amount of $49. 5 M over 5 years • 1915 (c) waiver approved on October 1, 2007 • Implemented on November 1, 2007 10

MYPAC Program - History • An array of services for Mississippi youth diagnosed with Serious Emotional Disturbance (SED). • Alternate services to traditional Psychiatric Residential Treatment Facilities (PRTF) that include: – – Intensive Case Management Wraparound Respite National Evaluation Assessment 11

MYPAC – Enrollment Requirements Youth may be eligible for MYPAC if they meet the: – Clinical criteria for PRTF admission; – Age requirements for admission; and – Financial criteria for Medicaid. 12

MYPAC – Providers and Services • Providers (Providing MYPAC services statewide) – Mississippi Children Home Services – Youth Villages • Service Delivery – Primary Support Coordinators (MCHS and YV) will coordinate all services – Family Support Specialist will act as an advocate for the family to ensure their needs are being met – Based on Individualized Service Plan – Wraparound Approach 13

MYPAC – Education & Outreach • To local communities • Focused toward sources who may refer youth to PRTF – Schools – Community Mental Health Centers (CMHCs) – Youth court judges & counselors – DHS social workers – Mental health providers 14

MYPAC – Program Enrollment As of Oct 21, 2009: • Total number enrolled sinception: 365 • Total number discharged since program inception: 180 • Number enrolled this waiver year: 196 • Current number enrolled: 185 – Male: 111; Females: 74 – 12 and under: 57; 13 -18: 128 – Transitions: 55; Diversions: 130 15

MYPAC – Local Evaluation • All youth in MYPAC will participate in the evaluation study – consent forms were signed • Control group of 50 youths from PRTF enrollees, by random selection, each year – Each youth is numbered, and the lowest numbered kid each week is selected to the control group, after parent’s consent • Use of CANS-MH for functional outcome assessment 16

MYPAC – Data • Data extracted from multiple data sources (e. g. standardized instrument, claims data) • A significant amount of time for data cleaning and tracking • Baseline, follow up data (6 mons, 12 mons, …) and discharge data • MYPAC program enrollees’ data and control group member data 17

MYPAC – Analysis File • 236 individuals in MYPAC and 62 in the control group, at the baseline • 77 MYPAC enrollees had 6 -month follow-up data, and 11 had 12 -month follow up • 88 of transition and 77 diversion cases • Enrolled since Nov, 2007 • Not all enrollees’ data were fully captured and reported yet 18

MYPAC – Demographics, By T&C 19

MYPAC – Demographics, By T&D There were only 40 total youths who got discharged but also a valid diversion/transition status, so the comparison at discharge was omitted. 20

MYPAC – Common outcomes at baseline 21

MYPAC – CANS items at baseline 22

MYPAC – Change of Common Outcomes 23

MYPAC – Change of CANS Outcomes 24

MYPAC – Change of Common Outcomes 25

MYPAC – Change of CANS Outcomes 26

Findings and Conclusions • Children in both MAPAC and control groups seem to have similar demographic characteristics at baseline; however, statistical test was not performed yet for this comparison due to lots of missing data and resulting small sample size for the control group. • Children transited and diverted to the MYPAC program also seemed to have similar demographic characteristics. • Children diverted into MYPAC program seem to have more involvement with the PRTF compared to those transited, based on the baseline data. • Both diversion and transition cases are observed with similar functional outcomes at baseline CANS assessment, with some minor difference. 27

Findings and Conclusions (Cont’) • A quick comparison of the average functional outcomes between baseline and the 6 -month, and baseline and discharge time points, respectively, suggest that children’s functional outcomes are improving in general – with more signs of increase than decrease. • However, no statistical test was done to confirm whether these directions of outcome change are statistically significant. • There are some suggested hints that children’s outcomes seem to improve relatively quickly during the first 6 months of program enrollment, but the effect seems to be diluted a little bit at the time when the youths were discharged. 28

Next Step In general, • Perform more statistical analysis to test the statistical robustness of the suggestive results; • Collect more control group data and do the cross-sectional analysis between MYPAC and control group youths; • Perform longitudinal analysis to test the sustainability of change of the functional outcomes; • Perform multivariate analysis to control for a series of factors that may explain the outcome change other than the MYPAC program status. 29

Thank you! Additional questions/comments, email me at: ywang@impaqint. com 30