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PPC Prepares Budget Proposal for FBMHS
September 29, 2001

The following information was developed by the Pennsylvania Partnerships for Children (PPC) with assistance from PCPA's Family Based members. Providers may want to use this information to encourage your legislators to include Family Based services in the Children's Health Insurance Program.

Department of Insurance
Proposal: Family Based Mental Health Services

The Need

Family Based Mental Health Services's (FBMHS) goal is to divert costly inpatient hospitalizations to community programming, reducing out-of-home residential placements for children up to 21 who meet the clinical criteria for severe emotional disturbance or serious mental illness. The United States Surgeon General Report on Mental Health Services (1999) indicates that "inpatient care consumes about half of child mental health resources based on the latest estimate available, but it is the clinical intervention with the weakest research support." Questions about excessive and inappropriate use of hospitals were raised in the early 1980s (Knitzer, 1982) and clearly documented thereafter in rising admission rates from the 1980s into the mid-1990s, without evidence of increased social or clinical need for such treatment (Weller et al., 1995).

According to the US Surgeon General's report, "since the 1980s, the field of children's mental health has witnessed a shift from institutional to community-based interventions. It covers a range of comprehensive community-based interventions, including case management, home-based services, therapeutic foster care, therapeutic group homes, and crisis services. Many of the evaluations to date offer a first glimpse into the benefits of these services and the extent to which they may be valuable for further examination. Of these interventions, the most convincing evidence of effectiveness is for home-based services."

A model similar to FBMHS known as Children and Youth Intensive Case Management (CYICM) was evaluated in two controlled studies. In the first study, the authors found that children in the program spent significantly more days in the community between episodes of psychiatric hospitalization and were hospitalized for fewer days than before enrollment (Evans et al., 1994). A subsequent study evaluated a random sample of 199 children enrolled in CYICM (Evans et al., 1996b). Findings at 3-year follow-up indicated significant behavioral improvements and decreases in unmet medical, recreational, and educational needs compared with findings at enrollment. As in the previous study, children who had been in CYICM for 2 years had spent fewer days in psychiatric hospitals and more days in community settings during the intervals between hospitalizations. This study went further to compare their hospital utilization with that by children not enrolled in the program. Although CYICM clients spent more days in psychiatric hospitals before enrollment, they used inpatient services after enrollment significantly less than did non-enrollees. CYICM clients' hospital admissions declined fivefold after enrollment whereas among non-enrollees the decline in admission rates was less than half that value. This difference translated into a savings of almost $8,000,000 for New York State, where the project took place.

In Pennsylvania, FBMHS is a behavioral health service package provided by a team of either two child mental health professionals or one child mental health professional and a child mental health worker. The services include intensive home therapy, casework, family support, school-based consultation and intervention as needed, and 24-hour, seven-day availability for crisis stabilization. FBMHS is available for a maximum of 32 weeks. Each team maintains an eight-family caseload to ensure team availability in crises.

The Department of Public Welfare, Office of Mental Health and Substance Abuse (OHMSAS) funds the program and developed the FBMHS clinical criteria. FBMHS development coincided with a change in Pennsylvania's mental health policy directing children to the least restrictive, most clinically appropriate environment, with the goal of keeping families intact.

The provider networks of the county-based public mental health system provide the Medicaid-funded FBMHS in all 67 Pennsylvania counties. FBMHS is in the HealthChoices benefit package and is offered as fee-for-service in non-HealthChoices counties. To access FBMHS services, a child must be Medicaid-eligible based on income or disability. Consequently, children who meet the clinical criteria for FBMHS assistance cannot get access because they exceed Medicaid income eligibility guidelines.

A 1997 Pennsylvania Community Providers Association study on FBMHS indicated the average length of service is 25 weeks at 4.6 hour per week. The average FBMHS team reported serving 12.2 families per year. The most common diagnoses are Attention Deficit Disorder (49 percent), Oppositional Defiant Disorder (28 percent), and Depression (23 percent). The average age at FBMHS admission is 12.

The Pennsylvania Community Providers Association showed that 88 percent of FBMHS participants avoided hospitalization or out-of-home placement. In a 2001 study, Chester County's Family First program found that 88 percent of its 56 children participating remained home, avoiding hospitalization or out-of-home placement. Both outcome studies show that FBMHS participants gained an average of nine points higher on the Global Assessment of Functioning (GAF) scale after admission and moved from "serious symptoms and impairment" to "moderate symptoms and impairment." In most cases, follow-up services such as outpatient mental health services are then implemented for the child and the family.

Recommendation

Add Family Based Mental Health Services to CHIP

Investment

Pennsylvania Partnerships for Children (PPC) recommends that FBMHS be added to the Children's Health Insurance Program (CHIP) benefit package.

Cost

According the Pennsylvania Department of Health (DOH), during FY99/00, there were 6347 children admitted to psychiatric hospitals. According to DOH, they spent 66,660 days in the hospital. Average length of stay is 10.5 days. Per diem rates at psychiatric hospitals range are approximately $1000 per day. Total cost for all psychiatric inpatient services for children is $66.6 million ($1000 per day x 66,660 patient days of care). However, about 80% of the children admitted were Medicaid recipients.

PPC estimates that less than 9% or 550 families would be served for 25 weeks, @ 4.6 hours a week. The maximum estimated cost is $6,813,290, based on the OMHSAS fee-for-service Medicaid rate of $107.72 per hour. This projected utilization could be much less because not every CHIP eligible child needing inpatient services can be diverted to FBMHS and may need other types of care such as residential treatment.

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