Office on Disability

MAKING SERVICES MORE ACCESSIBLE AND CHILD AND FAMILY CENTERED

OD:

• Change current fragmented service delivery by developing strong leadership and infrastructures to convert a silo approach to systems of care across all states.

• Provide technical assistance (TA) to states to develop governance structures that support the systems of care approach.

• Provide multiple access points for services to ensure a �no wrong door� approach.

• Offer federal incentive grants to state health and human services authorities (e.g., education, mental health, developmental disabilities, substance abuse, primary care, child welfare, juvenile justice, Medicaid, transportation, housing) to plan integrated systems of care. This requires increased interdepartmental collaboration and coordination.

• Insist on state/county interagency collaboration and inclusion of this population when awarding departmental/agency grants, waivers, or cooperative agreements.

• Promote the use of a single plan of care for each child based on need, not diagnosis, and regardless of funding.

• Increase access for families to non-clinical supports such as in-home help, respite care, after school services, family support and advocacy.

ACF:

• Include the systems of care needs of children with co-occurring disorders in the Family Support 360 grants.

• Use the array of ADD networks to highlight the comprehensive needs of this population and develop supporting leadership.

CMS:

• Assess how the current Systems Change grants and other Medicaid opportunities can help address systems integration challenges for which Medicaid has jurisdiction.

• Explore how co-occurring disorders can be incorporated into the Medicaid Disability Division�s strategic action plan.

HRSA/MCHB:

• Use the Federal Interagency Coordinating Council and the Medical Home Initiative to help address the comprehensive approach and leadership needed to support this population.

SAMHSA:

• Continue to address as part of mental health transformation, including obtaining support from the Senior Federal Workgroup

• Include attention to this target group in state infrastructure and systems of care grants, and ongoing TA efforts.

DED:

• Identify how current and future OSEP grants support systems infrastructure and leadership development.

• Identify how the IDEA can support systems infrastructure and leadership development.

FTA:

• Include this population in the continuing development of the nationwide human service transportation in continued work with federal departments on transportation one-stop information systems.

HUD:

• Identify how current public housing supports for families can help address this population�s housing needs.

DOJ:

• Identify how current interdepartmental funding (e.g., with SAMHSA) can include this population.

• Identify how all current and planned grants can include this population.

DOL:

• Address the needs of older youth who have fallen through the cracks and who may have co-occurring disorders to learn effective ways to help this group navigate through child welfare, juvenile justice, school and the labor force.

• Identify how DOL�s �no wrong door� programs can address this population.

SSA:

• Assess use of infrastructure grants addressing youth in transition and other demonstration funding to support this population.

ALL DEPARTMENTS:

• Examine the various federal interagency efforts to develop state/community leadership and foster infrastructure development.

• Family members are not consistently included or involved in decision making at all levels of government, training and service planning.

• Increase access for families to non-clinical supports such as in-home help, respite care, after school services, family support and advocacy.

• Include family concerns through the ACF/ADD Family Support 360 grants.

• Never should a family be forced to relinquish custody of a child in order to access the services the child needs.

• Increase access for families to non-clinical supports such as in-home help, respite care, after school services, family support and advocacy.

• Involve families in all discussions, service plan development and treatment so that the family can help drive the decision making.

HRSA/MCHB:

• Assess through the Federal Interagency Coordinating Council and the Medical Home Initiative how families of children with these co-occurring disorders are included in all aspects of planning at the federal, state, community, and provider levels and implement an action plan to enhance such involvement.

SAMHSA:

• Continue to address as part of the mental health transformation.

DOJ:

• Assess current initiatives and federal partnerships on how families are included and implement an action plan to enhance such involvement.

SSA, CMS, SAMHSA:

• Assess how more emphasis on providing families with purchasing power can enhance individual and family self-determination.

• Screening and early detection of co-occurring disorders are not consistently used on entry into child services.

• Restrictive and inconsistent eligibility criteria and limited access to services remain a challenge in meeting this population�s needs.

• Maintaining continuity of care is problematic as children transition between early childhood to school age and between adolescence to adulthood.

• Provide more early intervention services to identify children with co-occurring disorders and assure screening on entry into any state/county system.

• Train providers to recognize symptoms both at intake/referral and for children already receiving services.

• Provide training and technical assistance activities in order to identify and ensure utilization of evidence based screening tools which include attention to securing parental consent, and service linkages.

• Develop an appropriate single plan of care for these children based on need, not diagnoses, regardless of funding.

• Families should not be forced to relinquish custody of a child in order to access services.

• Provide a single location within the community where assessment and comprehensive wrap-around planning can occur.

• Address transitions between the early childhood/early intervention systems and the school age systems.

• Address transitions between the child and adult systems.

ACF:

• Use the array of service and system networks to highlight and address screening, service access and continuity of care for this population.

• Use the ADD networks to train providers in systems of care for this population including the importance of �no wrong door� service approach.

CMS:

• Investigate concerns that waivers negatively affect access and eligibility by being too categorical for this population.

HRSA/MCHB:

• Use MCHB Federal Interagency Coordinating Council and the Medical Home Initiative to address eligibility and screening barriers.

SAMHSA:

• Use the Mental Health Transformation Federal National Partnership to help address the eligibility and screening barriers of this population.

• Utilize available training and technical assistance programs to develop infrastructure supports and enhance providers� skills on screening and eligibility for this population.

• Collaborate with the Centers for Disease Control (CDC) on screening for this population.

• Explore collaboration with the Department of Defense (DOD) to facilitate coordination of services for deployed and redeployed military families.

DED:

• Assess how the IDEA and other initiatives/programs can help address the screening and eligibility needs of this population.

DOL:

• Address how ODEP and other DOL offices are addressing the screening, eligibility, employment and transition needs of older youth with these disorders.

SSA:

• Investigate how SSI might relieve screening and eligibility constraints imposed by Medicaid.

• Try to help the Office on Management and Budget (OMB) understand that it is economically wise to invest in screening, early detection and early intervention.

• Seek guidance from other federal departments regarding data on cost benefit and specific recommendations for OMB.

• Too many children with co-occurring disorders are placed in the child welfare or juvenile justice system where their needs are not understood and addressed, often due to lack of community services.

• Provide adequate community-based resources to prevent unnecessary criminalization and/or foster care placement.

• Address, through leadership and attention to administrative infrastructure development, current categorical funding and silo service delivery systems.

• Educate the juvenile justice and child welfare officials on identification of and community-based alternatives.

ACF:

• Use existing programs and initiatives to help address both avoidable child welfare placements and mechanisms to improve access to needed services for this target population.

• Identify how the IV-E waivers in the Children�s Bureau can be used to target this population to prevent unnecessary child welfare placements/parental relinquishment.

CMS:

• Investigate the concern that waivers are too categorical and are not offering the flexibility to fully address the complex needs of children with this class of disorders.

• Identify how co-occurring disorders can be incorporated into the Medicaid Disability Division�s Strategic Action Plan.

SAMHSA and DOJ:

• Identify how current and planned interdepartmental initiatives are or can address unnecessary out of home placements.

SSA:

• Investigate further how SSI might be used to help prevent unnecessary out of home placements by addressing Medicaid constraints.

ALL DEPARTMENTS:

• Assess current state plans as to preventing unnecessary child relinquishment.

INCREASING CAPACITY IN THE FIELD

OD:

• Inadequate professional training on screening, assessing, treating and structuring services for children with co-occurring disorders.

• Increase understanding and awareness of the needs of children with co-occurring disorders among primary care providers.

• Increase understanding and awareness of the needs of children with co-occurring disorders among child care providers and educators.

• Integrate developmental disabilities and mental health services within the schools and the primary care environment.

• Recruit child psychiatrists and psychologists and other professionals to work with young people who have co-occurring disorders including autism.

• Help higher education state systems develop multi-disciplinary training programs for staff working with this population.

• Develop scholarships and education loan forgiveness to encourage professional cross-training.

• Promote development of federal, state and county interdepartmental cross-training programs.

ACF:

• Use the training capacity of the ADD networks to specifically target TA and training related to this population.

HRSA/MCHB:

• Continue to develop the Medical Home Initiative that is working with pediatricians to engage in early identification of behavioral health and developmental needs.

SAMHSA:

• Continue and enhance training and technical assistance activities to influence practices in screening, treating, and structuring services.

ALL DEPARTMENTS:

• Assess current and planned training and TA on screening, treatment and service structures.

FACILITATING INTERAGENCY COLLABORATION AND PARTNERSHIP AT THE LOCAL, STATE AND FEDERAL LEVEL

OD:

• Current system structures do not support professional collaborations among multiple systems.

• Provide TA to states to develop governance structures that support systems of care.

• Offer incentive grants in order to motivate coordination across systems.

• Insist on interagency collaboration and the system of care model when awarding federal departmental/agency grants, waivers, or cooperative agreements.

• Coordinate among federal departments/agencies at the federal level.

SAMHSA:

• Utilize state infrastructure and other grants to help build state/county systems of care targeting this population.

• Identify how current and planned SAMHSA - federal interagency efforts can increase collaboration and reduce duplications for this population.

ALL DEPARTMENTS:

• Assess how current and future funding can be used to provide incentive grants, support state and county interagency collaboration and coordination for this population.

PROVIDING MORE FLEXIBILITY FOR FINANCING SERVICES BASED ON NEEDS

OD:

• Financing mechanisms and community needs are not in alignment.

• There is limited investment in screening, prevention and early intervention which are needed to end the ineffective and wasteful practice of addressing needs at the point of crisis.

• There is limited state use of Medicaid waivers to help address the service needs of these children.

• Private insurance shifts costs to the government.

• Increase access for families to non-clinical supports such as in-home help, respite care, after school services, family support and advocacy.

• Identify and remove federal barriers to braiding and blending funds.

• Provide more flexible federal funding with the requirement to continue maintenance of effort and retain the entitlement nature of programs such as Medicaid and child welfare.

• Provide Medicaid waivers for services across systems.

• Provide clarification on Medicaid covered services.

• Provide technical assistance to states and communities so they can use an array of financing approaches including risk-based to re-direct expenditures from the �deep end� or more expensive chronic and acute care services.

• Eliminate the cost shift by insurance companies to the government/Medicaid.

ACF:

• Look at IV-E waivers in the Children�s Bureau to determine ways to target coordinated financing for this population.

CMS:

• Investigate the concern that waivers are too categorical and are not offering the flexibility to fully address the complex needs of children with this class of disorders.

• Explore issue of how co-occurring disorders could be incorporated into the Medicaid Disability Division�s Strategic Action Plan.

• Assess how current round of system change grants might help address challenges of this population.

• Assess impact of private insurance cost-shift to Medicaid and identify mechanisms to help address.

SSA, ACF, CMS, HRSA, SAMHSA:

• Assess how more emphasis on providing families with purchasing power can enhance individual/family self-determination.

SSA:

• Investigate further how SSI might be used to relieve some of the constraints imposed by Medicaid in serving children with both developmental and emotional/substance abuse disorders.

• Try to help the Office on Management and Budget (OMB) understand that it is economically wise to invest in screening, early detection and early intervention.

• Seek guidance from other federal departments regarding data on cost benefit and specific recommendations for OMB.

ALL DEPARTMENTS:

• Identify how discretionary and categorical funding can include attention to financing strategies for this population group.

SUPPORTING TECHNOLOGY AND RESEARCH

OD:

• Facilitate interdepartmental supporting actions.

• There is a limited research on this population, effective treatments and service delivery systems within the public health system.

• There is limited data sharing, real time data utilization and supporting technology at the federal, state and community levels to enhance development of systems of care, clinical decision-making and performance monitoring tied to cross-system outcomes.

• Launch a public health approach to better understand this population.

• Support research that will foster a healthy growth of evidence-based practices.

• Develop clinical practice guidelines and quality monitoring systems tied to cross-system outcomes.

• Provide real time data across systems to support clinical decision-making, utilization management, and quality improvement.

CDC:

• Consider coordination of an intergovernmental (e.g., with SAMHSA, ACF, CMS, NIH, SSA, DED, DOL, etc.) research/evaluation action plan, assessment of interdepartmental evidence based practices and public health awareness approaches targeting this population.