Policy and Service Development

Prepared by Ken Chan

Chief Officer (Children and Youth)

Hong Kong Council of Social Service

Policy issues for LA mental health system

• Integration of additive problems in mental health system under the same Bureau

• “Single point of responsibility” in Policy and service level

• Continuum of Care and Collaboration among Departments and different sectors

• Abiding law for the protection of the deprived

Trends of Service Development1. Initiate new service for early identification of

mental health problem at the Age 0-5 2. Initiate children scorecard to help on monitoring

the overall quality child care service including mental health

3. Initiate the movement of evidence-based practice in all level of service planning and policy decisions.

4. Prevention and treatment of co-occurring mental disorder and other problems, e.g substance abuse, suicide, unemployment, HIV etc.

5. Accessibility of service for ethnic minorities

Evidence-Based Practice

• Trend in the future mental health practice and service provision

Goals(1) To highlight the available social science evidence on

mental health services for foster children, from which service systems models can be developed

(2) To encourage the integration of known research into the planning, development and delivery of mental health services to children in foster care

(3) To dispel some of the prevailing myths and misperceptions about the mental health needs and best treatment options for children in foster care

(4) To provide service information, implications and recommendations designed to improve the delivery of mental health services to foster children.

Integrating evidence-based elements in direct practice

1. In general, research examining outcomes for community-based and institutional interventions has not used efficacy trials in which and active intervention is compared to a “passive” one such as placebo or wait-list controls.

2. The terms strong, moderate and weak not only refer to the scientific rigor of the research design, but also to the number of studies carried out and the outcomes obtained.

3. The clinical trials of multi-systematic therapy, a treatment supported by strong evidence, all studies have employed a random assignment design, there have been several replications and positive long-term outcomes have been consistently obtained.

4. Interventions with moderate evidence are those where either there is less rigor in the design or there has only been one study demonstrating a positive outcome for the intervention.

5. Finally, interventions with weak evidence either show poor outcome or do not employ rigorous research designs.

Case study: Evidence-Based Strategies for Working with Foster Children

Program or

Treatment

Program Description Target Population Research Status

Wraparound

A family-focused, strengths-based program where intensive and comprehensive social, mental health and health services are “wrapped” around children and their families (biological, adoptive and/or foster families) to reinforce natural family supports.

Foster children with emotional and behavioral problems

EFFECTIVEFostering Individualized Assistance ProgramDevelopers : Hewitt Clark and colleagues University of South Florida

Treatment Foster Care

Parent Management Training based on social learning theory. Foster parents are the primary interventionists. Foster parents are provided with training, consultation, and clinician support.

1. Children and adolescents with chronic delinquency and conduct problems

2. Adolescents with severe emotional disturbance; and

3. Latency age children with behavior problems

EFFECTIVEMultimodal Treatment Foster CareDevelopers:Patricia Chamberlain and colleaguesOregon Social Learning Center

Program or

Treatment

Program Description Target Population Research Status

Early Intervention Program

Multidisciplinary team approach which includes foster parents. Includes behavior management foster parent training, screening for developmental delays, activity-based curriculum and long term placement planning.

Maltreated preschoolers

PROMISINGEarly Intervention Foster CareDevelopers: Phil Fisher and colleaguesOregon Social Learning Center

Foster Parent Training:An Attachment Theory Prospective

Foster parents are taught to recognize and respond sensitively to infants problematic attachment strategies

Foster parents caring for infants

PROMISINGDevelopers : Mary Dozier and colleaguesUniversity of Delaware

Institutional and Community-Based Interventions, by Relative Level of

Supporting EvidenceStrong Evidence 1) Multisystemic Therapy (MST)

2) Intensive Case Management, Wraparound

3) Treatment Foster CareModerate Evidence

1) Family Education and Support2) Mentoring3) Partial Hospitalization4) Respite Care

Weak Evidence 1) Institutional Interventions Hospital, Residential or Group Home

Target Diagnosis or

Disorder

Treatment Research Status

Anxiety Systematic desensitization and reinforced practice reduce phobic symptomsCognitive behavior therapy reduces anxiety symptoms and fearsCoping Cat – cognitive behavioral intervention reduces anxiety symptoms and fears

EFFECTIVE

Conduct Problems

Anger control therapy, anger coping therapy, assertiveness training, delinquency prevention program, multi-systemic therapy, parent-child interaction therapy, parent training program, problem solving skills training, rational-emotive therapy, and time-out plus signal seat treatment.

EFFICIACIOUS

Evidence-Based Treatments for Childhood Mental Disorder

Target Diagnosis or Disorder

Treatment Research Status

Depression – Children and Adolescents who exhibit symptoms of depression (not necessarily clinically diagnosed)

Cognitive Behavior Therapy

Self-control therapy

EFFICAICOUS

Attention-Deficit Hyperactivity Disorder (ADHD)

Behavioral parent and teacher trainingSystematic programs of contingency management in specialized classrooms

EFFICIACIOUS

Disruptive Behavior Parent Training Program – Living with ChildrenVideotaped parent modeling program

EFFECTIVE

Prevention and treatment of Co-occurring

Mental Disorder and other problems • 二零零四年，世界心理衞生聯盟

選取了「世界精神健康日」的主題為「身體與精神健康的關係 -精神及生理失調的共存」 (The Relationship Between Physical and Mental Health: Co-occurring Mental and Physical Disorders)

• Implication for mental health service in Hong Kong

• Do we have relevant data on this issue ?

• How does our practice right now in handling this issue ?

Mueser et al. (1998) reviewed two decades of etiological theories related to co-occurring substance abuse disorders and mental disorders. Based on that analysis, they offered 4 general models that synthesize current thinking in the field regarding the etiology of co-occurring substance abuse disorders and mental disorders (Anthony, 1991; Kosten and Ziedonis, 1997; Kushner and Mueser, 1993; Lehman et al., 1989; Meyer, 1986; Weiss and Collins, 1992):

• Common factor models. High rates of co-morbidity are the result of risk factors4 shared across both severe mental illness and substance abuse disorders.

4 Risk Factors are factors such as low socioeconomic status or relationship loss and bereavement that increase an individual’s, a group’s, or a community’s vulnerability to mental illness or substance abuse.

Models on Co-Occurring Problems

• Secondary substance abuse disorder models. Severe mental illness increases a person’s chances of developing a substance abuse disorder.

• Secondary mental/psychiatric disorder model. Substance abuse precipitate severe mental illness in people who would not otherwise develop a severe mental illness.

• Bi-directional models. Either severe mental illness or substance abuse disorders can increase a person’s vulnerability to developing the other disorder.

The Healthcare for Communities Survey

• Among people with co-occurring disorders, this study found that 72 percent did not receive any mental health or substance abuse treatment over the previous year (Watkins et al., 2001).

• Fewer than 25 percent of individuals with co-occurring disorders received appropriate mental health services, and only 9 percent received supplemental substance abuse servies.

Current Situation on Co-Occurring Problems

• Many Individuals Receive No Care or Inadequate Care

• The National Co-morbidity Survey Replication.

• Preliminary results are incompletely weighted and based on the first half of the NCS-R survey.

Rates of Treatment by Type (Mental Health, Substance Abuse) and by severity Level of the

Disorder (NCS-R)

Level of Substance Abuse Disorder

Type of Treatment Level of Mental Disorder

12-month serious mental illness

12-month other mental illness

12-month substance

dependence

Neither MH nor SA

29% 71%

MH only 49% 25%

SA only 3% 1%

Both MH and SA 19% 4%

Co-Occurring Substance Abuse Disorder and Mental Disorder Conceptual Framework

The Science-to-Services Agenda: Closing the

Gap from Research to Practice (1) • The various windows of opportunity across the life span in

which co-occurring disorders may be prevented.

• The effectiveness of specific interventions (e.g. group therapy, case management) for people who have co-occurring disorders.

• The identification of validates, reliable, and standardized screening and assessment tools (including testing for drugs and alcohol), for co-occurring disorders that are age, gender and race/ethnicity appropriate and can be used by a range of providers in varying service settings.

The Science-to-Services Agenda: Closing the

Gap from Research to Practice (2)

• Epidemiological studies regarding cohorts of people with co-occurring substance abuse disorders and mental disorders whose levels of disease severity place them into one of the four quadrants of the conceptual framework developed for co-occurring disorders.

• The cost-effectiveness of varying levels and types of interventions – whether prevention or treatment – for people with co-occurring disorders, including costs and cost-offsets in other service systems, such as criminal justice, primary health care, child welfare, homeless services, and emergency medicine.

• Service system research to determine how financial incentives and accountability measures affect service system change.

High risk group

• Children and adolescents• Women and men who have been physically and/or

sexually abuse• People who are homeless• People with HIV/AIDS• People who are making the transition from the criminal

justice system to the community

Technical Assistance

• The Agency’s training and technical assistance centres6 will be encouraged to coordinate with one another to facilitate exchange of information and technologies about co-occurring disorders to reach the greatest number of providers possible, making best use of SAMHSA’s resources and knowledge dissemination capacity.

• Consistent evaluations on the impact of these training and technical assistance centers will demonstrate how they have made best use of SAMHSA’s resources and knowledge dissemination capacity.

• 6 SAMHSA’s training and technical assistance centers include the CSAT Addiction Technology Transfer Centers (ATTCs) and Treatment Improvement Exchange (TIE), the CSAP Centers for the Application of Prevention Technology (CAPTs), and the CMHS Mental Health Services Technical Assistance Centers.

Technical Assistance (2) • The new Treatment Improvement Protocol for

substance abuse services providers, Substance Abuse Treatment for Persons with Co-Occurring Disorders (CSAT, in press).

• The Integrated Co-Occurring Disorders Treatment Toolkit, being developed and evaluated for use by mental health administrators and providers, consumers, and family members as part of the SAMHSA Evidence-Based Practices Project.

• The technical assistance report, strategies for Developing Treatment Programs for People with Co-occurring Substance Abuse and Mental Disorders.

Prevention, Early Identification, and Early Intervention

• Reaching out to primary care practitioners, to educate them about the importance of screening and assessing their patients for the presence of mental and substance abuse disorders, and to provide them with information about appropriate screening and assessment methods, including alcohol and drug testing resources.

• Supporting activities to help communities adopt and adapt effective, evidence-based family interventions to reduce the risks for substance abuse and mental disorders.

• Further developing and broadening the Agency’s efforts to identify and disseminate evidence-based programs for the prevention and treatment of co-occurring disorders.

• Financial support: creative use of the 20 percent prevention set-aside in the SAPT Block Grant to initiate activities that may forestall or prevent the development of substance abuse disorders in individuals at risk for development co-occurring mental disorders.

• Working with the U.S. Department of Education to enhance partnerships at the State and local levels to respond to prevention and treatment needs of children and adolescents in schools and in mental health and substance abuse settings.

Service Arrangement

• Persons with dual diagnosis are served within the mental health service when they are psychiatrically high – substance abuse low (substance abusing mentally ill persons);

• Persons with dual diagnosis are served within the substance abuse service when they are substance abuse high – psychiatrically low (complicated chemical dependency, or psychiatrically complicate substance dependence);

• Persons are served using shared resources when they are psychiatrically high – substance abuse high (the substance dependent mentally ill).

Lessons Learned

• Strong intention of State and Federal Government to collect relevant data is important for identify and track the progress of the problem.

• Single point of responsibility and professional division of labour help the development of strategies in handling co-occurring case.

Program Lessons • Retention is critical; consumers shouldn’t be

“scared” away;• Consumer progress should be viewed in small

steps; • The more options provided, the more empowered

the consumer;• Staff competence to work with persons with dual

diagnosis consumers should be the expectation; • Staff must be cross-trained in both fields.

Reference:

n Larsenich, L. (2002). Evidence-Based Practices in Mental Health Service for Foster Youth. Sacramento, CA: A California Institute for Mental Health Publication.

n Substance Abuse and Mental Health Services Administration. (2002). Report to congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. Washington D. C. : U.S. Department of Health and Human Services

L.A. Mental Health Service Financing

Prepared by Ken Chan

Chief Officer (Children and Youth)

Hong Kong Council of Social Service

Basic Structure• Fall into the US health care system: 4 routes• 1. Medicare for the elderly and disabled;• 2. Mediaid for low-income/ public assisted individu

als and persons with certain disabilities• 3. Employer-subsidized coverage in the workplace;• 4. Self-purchased coverage available through privat

e insurance companies.

Medicare (Federal)

• Medicare is a federal health insurance program which provides benefits for eligible persons. There are 2 parts to the program: Part A is hospital insurance and Part B is medical insurance. Medicare does not cover everything.

Medi-Cal

• Medi-Cal is Califonia’s program to pay for medical care for low-income people, especially families, children, the elderly, and people with disabilities.

Problems

• Coverage: doctor charge over the Medicare allowable charge

• Access to care:• Facilities so overloaded that access is unrealistic• Physicians’ resistance to treating such patients has

been ascribed to many causes, including low and delayed payment, paperwork, cultural or language problems, noncompliance.

Implication

• HK mental health care financing, how about the distribution of youth mental health ? Is it same as the adult ?

• The availability of service, waiting period and linkage between services.