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Mobile Response and Stabilization Services (MRSS): Two State Perspectives On A Key Element of A Statewide
Children's System of Care
Wyndee Davis, Danielle Gasperini, Ann Goldman, Cinaida Anthony, New Jersey
Ann Polakowski, Nevada
Dayana Simons, University of Maryland, TA Network
PresentersNevada:
Ann Polakowski
New Jersey:
Cinaida Anthony
Wyndee Davis
Danielle Gasperini
Ann Goldman
University of MD/TA Network:
Dayana Simons
MRSS: Context and Evolution
Dayana Simons
TA Network Lead for Clinical Best Practices, Wraparound and Workforce DevelopmentHealth Program Director, The Institute for Innovation and ImplementationUniversity of Maryland School of Social Work
Why Include MRSS In a Crisis Continuum?
• Children, youth, young adults and families can initiate care based on a self-defined crisis
• Engaging families in a culturally and linguistically competent crisis response is essential not just for reducing risk in the current crisis and preventing future crises but also for developing trust
Massachusetts Parent/Professional Advocacy League. (2011). Crisis Planning Tools for Families: A Companion Guide for Providers. Retrieved from https://www.masspartnership.com/pdf/Crisis-Planning-Tools_Guide_for_ProvidersFinal.pdf
The Value of MRSS within a Crisis Continuum
• Designed to intercede upstream, before urgent behavioral situations become unmanageable emergencies
• Instrumental in averting unnecessary ED visits, out-of-home placements and placement disruptions, and in reducing overall system costs.*
• Keep a child, youth or young adult safe at home, in the community, and in school whenever possible.
• Viable alternative to acute care and residential treatment because they consistently demonstrate cost savings while simultaneously improving outcomes and achieving higher family satisfaction.
*Technical Assistance Collaborative. (2005). A Community-Based Comprehensive Psychiatric Response Service: An Informational and instructional monograph. Retrieved from http://tacinc.org/media/13106/Crisis%20Manual.pdf
Federal Guidance• 2013 CMCS/SAMHSA Joint Informational Bulletin Medicaid reimbursable home and
community-based services for children and youth with complex behavioral health needs.
• Named several services critical to developing a high-quality crisis continuum, including mobile crisis response and stabilization and residential crisis stabilization
• Interdepartmental Serious Mental Illness Coordinating Committee Charter (ISMICC) first report to Congress (2017) recommended:
• Defining and implementing a national standard for crisis care
• Developing an integrated crisis response system to divert people with SMI and SED from the justice system
• Crisis intervention team training for those in criminal justice
Core Components • Home- and community-based stabilization• Care coordination/case management• On-site, face-to-face therapeutic response • 24/7 access• Comprehensive assessment• Crisis intervention and stabilization• Psychiatric consultation• Referrals and linkages to other services and supports• Psychopharmacology • ‘Crisis’ is defined by caller
“Original” Best Practice Approaches
• Milwaukee County, Wisconsin:
• Mobile Urgent Treatment Team (MUTT)
• New Jersey:
• Mobile Response and Stabilization Services
• Connecticut:
• Emergency Mobile Psychiatric Services (EMPS) Mobile Crisis Intervention Services
TA Network Peer Curriculum• Began April 2016
• Twice-yearly, 2-day Convenings (April/May and December)
• Each Convening Includes:• Didactic overview of best practice approaches (NJ, CT
and Milwaukee County, WI)• Peer presentations • Facilitated affinity groups • Targeted TA on individual team goals• Optional ride-along experience
TA Network Peer Curriculum (cont.)• Limited to 50 participants
• Online Application Process
• Open to Non-grantees
• Teams Encouraged to Include:
• Key cross-systems leadership and stakeholders
• Designated decision makers
TA Network Peer Curriculum Participants To Date
• Alaska*
• California
• Colorado
• Florida*
• Georgia
• Guam*
• Illinois
• Indiana*
• Kansas*
• Maryland
• Michigan*
• Minnesota
• Nevada*
• New York
• North Carolina*
• Ohio*
• Oklahoma*
• Pennsylvania*
• South Carolina*
• Tennessee
• Utah
• Virginia
• Washington
TA NetworkResources &Opportunities
• Best Practice Presentation Videos• TA Telegram (August 8)
• Past Webinars • http://theinstitute.umaryland.edu/our-
work/national/network/cbps/multimedia/
• December 2018 MRSS Peer Meeting• Application in TA Telegram (August 13)
Children’s System of CareMobile Response and Stabilization Services
Wyndee DavisAssistant Director,
Community Services
Children’s System of Care (CSOC)
(formerly DCBHS)
Child Protection & Permanency
(formerly DYFS)
Family
& Community
Partnerships
Office of Adolescent Services
New Jersey Department of Children and Families
Commissioner
Division on Women
15
NJ Children’s System of Care
• Serves children, adolescents, young adults under 21 with emotional and behavioral health care challenges, intellectual/ developmental disabilities, and/or substance use challenges
• CSOC is committed to providing these services based on the needs of the child and family in a family-centered, community-based environment.
• Statewide services with access through a single point of entry
• Voluntary and on Medicaid platform
• Local System partners are located in the community and aligned with Court Vicinages
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System of Care Values and Principles Drive ApproachYouth Guided & Family Driven
Community BasedCulturally/Linguistically Competent
Strength Based
Unconditional Care
Promoting Independence
Family Involvement
Collaborative
Cost Effective
Comprehensive
Individualized
Home, School & Community Based
Team Based
Children’s System of Care ObjectivesTo Help Youth Succeed…
At Home
In School
In the Community
Successfully living with their families and reducing the need for out-of-home treatment settings.
Successfully attending the least restrictive and most
appropriate school setting close to home.
Successfully participating In the community and becoming independent, productive and law-abiding citizens.
Service Array Expansion to Reduce Use of Deep End Services
LowIntensityServices
Out of Home
Outof
Home
Intensive In-CommunityWraparound – CMOBehavioral AssistanceIntensive In-Community
Lower Intensity ServicesOutpatientPartial Care
After School ProgramsTherapeutic Nursery
Prior to Children’s System of Care Initiative Today
NJ Children’s System of Care History
1999NJ wins a federal grant that allowed us to develop a system of care.
2000 - 2001NJ restructures the funding system that serves children. Through Medicaid and the contracted system administrator, children no longer need to enter the child welfare system to receive behavioral health care services.
2006The Department of Children and Families (DCF) becomes the first cabinet-level department exclusively dedicated to children and families [P.L. 2006, Chapter 47].
2007 – 2012The number of youth in out-of-state behavioral health care goes from more than 300 to three.*
January 2013Intellectual/developmental disability (I/DD) services for youth and young adults under age 21 is transitioned from the Department of Human Services (DHS) Division of Developmental Disabilities to the DCF Children’s System of Care (CSOC).**
May 2013Unification of care management, under CMO, is completed statewide.
July 2013Substance use treatment services for youth under age 18 is transitioned from DHS, Division of Mental Health and Addiction Services, to DCF/CSOC.
*How did we do this? Careful individualized planning and the development of in-state options (based on research about what youth need) using resources that were previously going out of state.
**Youth with I/DD in OOH programs or at risk of OOH, are transitioned July 2012
December 2014Integration of Physical and Behavioral Health is initiated in Bergen and Mercer County with expected Statewide rollout
July 2015NJ wins a Federal SAMHSA Grant for System of Care -Expansion and Sustainability
Department of Children and FamiliesDivision of Children's System of Care (CSOC)
Trauma Informed SOC, Utilizes an Integrated Approach to Care Embedded in System of
Care Approach (values and principles)
Policy Authority, Funding Agency Approves and manages the Provider Network
(BH carve out; Providers bill on fee for service basis)
Contracted System
Administrator
(ASO+)Single Point of Entry and Access to Care
24/7Triage, Utilization Management
Care CoordinationAuthorizes Services
Non risk basedHosts CSOC’s MIS (EHR and Data)
Mobile Response & Stabilization Services
Crisis response and planning; 24/7/365 within 1 hour
Dept. of Human Services
Division of Medical Assistance and Health
Services (Medicaid)
Client
Case
Placement
Dept. of Human Services
Division of Mental Health and
Addiction Services
Dept. of Human Services
Division of Developmental
Disabilities
Ru
tge
rs U
BH
C T
rain
ing
an
d T
ec
hn
ica
l A
ssis
tan
ce
--T
rain
s A
ll Syst
em
Pa
rtn
ers
, Fa
mili
es
Care Management OrganizationUtilizes Wraparound model to serve youth and families with moderate and complex needs; designated
health home entity
Family Support Organizations
Family-led peer support and advocacy for
parents/caregivers and youth group
CANS
ASSESSMENT TOOL Utilized
in Triage, for
Treatment
Planning and Outcomes
Tracking
Other Authorized Services includes but is not limited to: Biopsychosocial Assessments In home Clinical/Therapeutic
Out of Home Care (OOH) Partial Hospitalization/Partial Care
Substance Use Services In home Behavioral for I/DD youth
Family Support Services for I/DD Youth Non Medical Transportation
Interpreter Services Outpatient
Assistive Technology
• 1115 Waiver-Children’s Supports Waiver, I/DD and SED• State Plan Amendments
• Targeted Case Management-CMO
• Psych under 21 Benefit-OOH Programs• Rehabilitative Option-MRSS, IIC/BA, Out of Home
• State Option to Provide Health Homes• Flex Funds
Populations Served are youth (and their families) with one or more of the following: • Behavioral health challenges• Substance use challenges
• Intellectual/developmental disabilities• Autism
**Youth with multisystem involvement:
child welfare and/or juvenile justice
Children’s Interagency Coordinating Council
(CIACC)-One per county (21)-local planning
bodies
Child Family
TeamsPhysical Health
Integration
State and Federal Appropriations
Title XIX and Title XXI
Yo
uth
an
d Fa
mily
Vo
ice
Statewide Youth
Ambassador
Statewide System of Care
15 Service Areas
Cover 21 Counties
Mobile Response and Stabilization Services
Statewide
Crisis Defined…
A crisis occurs when:
• One’s sense of balance is disrupted
• Coping/problem solving skills used in the past are not working
• Life functioning is disrupted
Crisis is defined by the person/family experiencing it!
22
NJ MRSS Mission and GoalMobile Response and Stabilization Services:
• Help youth and their families who are experiencing an emotional or behavioral stressor by interrupting the family-defined crisis and ensuring youth and their families are safe and supported.
• Provide on-site assessment, intervention, support and skill building necessary to stabilize a youth’s behavior toward improved functioning, living situation stability and community involvement.
• Collaborate across youth-serving systems to support youth and family engagement and coordinate supports to help youth and families feel better.
• Prevent ER visits, psychiatric hospitalization, system involvement including placement in foster care, and out of home treatment.
23
NJ MRSS Program Access
Youth and Young Adults under 21 experiencing Family Defined Crisis
•24/7 Single Point of Access: •CSOC Contracted Systems Administrator (CSA)
•Clinical Triage and Criteria
•No System Involvement Required
•Parent/Caregiver Verbal Consent
•Warm Line Connection with local MRSS
•MRSS intervention response
24
NJ MRSS Program Structure
• 24/7 Community Response – Where You Are, Anywhere in NJ in 1 Hour
• Voluntary
• 72 Hour Initial Intervention
• Up to 8 Week Stabilization Period
• Provider Network Connection
NJ MRSS Program Structure (continued)• County Based Organization within System of Care Structure
• Connection with Family Support Organization
• Staffing Model
• Training, Certification and Supervision
• Crisis Assessment Tool (CAT)
• State and Local System Collaboration
Trends: MRSS Dispatches by Month 2011 - Present
2,646
1,743
1,059 1,201
1,878
2,550
2,1791,907
2,3912,522
2,6952,432
0
500
1,000
1,500
2,000
2,500
3,000
January March May July September November2011 2012 2013 2014
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Trends: MRSS Youth Served by Age GroupApril 2018 N = 2,432
MRSS trend over time points to greater number of dispatches for youth under 14 currently than upon inception of program.
Across services, children 13 years and younger represent forty-eight percent of the youth being served. N = 38,071
29
Trends: MRSS Youth Served by GenderApril 2018 N = 2,432
30
Trends: MRSS Youth by Race/EthnicityApril 2018 N = 2,432
31
Trends: Youth Served by MRSS with CP&P InvolvementApril 2018 N = 2,432
CPP Involved
8.93%
Not CPP Involved91.07%
CP&P Involved Youth N = 217
Youth Served by MRSS with DD EligibilityApril 2018 N = 2,432
DD Eligible, 1.93%
Not DD Eligible, 98.07%
DD Eligible Youth N = 47
Providing Integrated Care
33
34
Trends: NJ FamilyCare Eligibility of Youth Served by MRSS
22.79%
71.90%
5.31%0.70%
0%
10%
20%
30%
40%
50%
60%
70%
80%
CSOC Med Active Med/NJF.C./Other
No Medicaid 3560-500 Series
Have Youth Remained in the Same Living Situation Since Initial Contact / Intervention by MRSS?
35
Remained in Living Situation97.48%
Did Not Remain in
Living Situation
2.52%
Youth Transitioned in April 2018
Total N = 2,615Remained N = 2,549
Since its inception in 2004, MRSS has consistently
maintained 94 % of children in their placement at the time of service, including children who are involved
with the child welfare system. Families have
reported high satisfaction with services, with a 250
percent increase in families accessing MRSS.
For more information…
Children’s System of Care:
http://www.state.nj.us/dcf/families/csc/
PerformCare Member Services:
877-652-7624www.performcarenj.org
Crisis Text Line, Text ‘NJ’ to 741741
37
State of Nevada
Ann Polakowski, LCSW
Children’s Mobile Crisis Response Team
Mobile ResponseProgram
Mission & Objectives
Objectives:
• Support and maintain youth in their home and community environment
• Promote and support safe behavior in youth in their homes and community
• Reduce admission to Emergency Departments due to a behavioral health crisis
• Facilitate short term inpatient psychiatric hospitalization when needed
• Assist youth and families in accessing and linking to on-going support and services
Mobile Crisis Response Team strives to help Nevada children and adolescents live happily and safely in their homes and community
Mobile ResponseProgram
Values
• Respond immediately to children and families during times of behavioral/mental health crisis.
• Reduce Emergency Department visits for psychiatric crisis by providing immediate response to youth exhibiting behavioral/mental health crisis.
• Provide services that are family-driven, culturally competent, community based and consistent with Nevada System of Care principles.
• Assure safety and continuity of care through individualized strategies implemented through a wraparound-based, team approach.
• Facilitate linkage and access to community services using a Child and Family Team process.
History of Nevada Mobile Response
Clark County Consortium 10 year plan, Emergency Department concerns in media and legislature
Spring 2013 - Workgroups at local level begin to meet, champions identified, stakeholder meetings held
November 2013 - 5 positions hired in Clark County
January 2014 - Clark County hotline goes live
Summer of 2014 - Clark County expansion approved, Washoe County mobile planning begins
October 2014 - Washoe County hires 10 positions, Clark more than triples in size and expands hours
November 2014 – Washoe County hotline live, takes first calls
October/November 2016 - Clark County goes 24/7/365, Rural Mobile funded and program begins
Statewide Coverage
Reno MCRT
Las Vegas MCRT
• Rural MCRT serves anywhere in Nevada not inside a red box
New Hampshire, New Jersey, Vermont, Massachusetts, Delaware, Rhode Island, and Connecticut geographically fit inside the state
of Nevada.
State of Nevada MCRT January 8, 2014 To May 31, 2018
4,717Youth Served
To Date
14% Hospitalized
for Safety
86% Stabilized with
Safety Plan
163Total Hotline Calls
956
1,638
2,371
2,671
96 Total Responses
603
974
1,553 1,533
FY2014 FY2015 FY2016 FY2017 FY2018 to 5/31
NV MCRT Statewide
Who Refers To MCRT?
9%
3%
4%
5%
13%
32%
34%
Other/Unknown
Community Agency
Child Welfare
Law Enforcement/JJS
Parent/Guardian/Relative
School
Emergency Department
Why Do We Receive Calls?
2%
1%
2%
2%
3%
3%
3%
4%
6%
7%
9%
56%
Other/Unknown
Runaway and CSEC
Psychosis
School problems, school refusal, peer issues
Anxiety, trauma, abuse, grief
Physical aggression, anger, property damage
Depression
Homicidal ideation/plan
Self-injury
Severe parent/child conflict
Child behavior problem
Suicidal ideation/behavior
Where Do We Respond?
2%
1%
2%
3%
12%
13%
31%
35%
Unknown
Community Agency
JJS Location
Child Welfare Location
School
DCFS/MCRT Office
Private Residence
Emergency Room
Hotline Calls:Peak Mid-Week and Drop Sharply Over The Weekend
0
100
200
300
400
500
600
700
800
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
The Hotline Is Busiest 10am to 2pm
Responses Peak In Early Spring MCRT Is Slow In June and July
0
50
100
150
200
250
Jan
uar
y 2
01
5
Feb
ruar
y
Mar
ch
Ap
ril
May
Jun
e
July
SFY
20
16
Au
gust
Sep
tem
ber
Oct
ob
er
No
vem
ber
Dec
em
ber
Jan
uar
y 2
01
6
Feb
ruar
y
Mar
ch
Ap
ril
May
Jun
e
July
SFY
20
17
Au
gust
Sep
tem
ber
Oct
ob
er
No
vem
ber
Dec
em
ber
Jan
uar
y 2
01
7
Feb
ruar
y
Mar
ch
Ap
ril
May
Jun
e
July
SFY
20
18
Au
gust
Sep
tem
ber
Oct
ob
er
No
vem
ber
Dec
em
ber
Jan
uar
y 2
01
8
Feb
ruar
y
Mar
ch
Ap
ril
May
South North Rural
SUM
MER
SUM
MER
SUM
MER
SPRINGSPRING
SPRINGSPRING
Insurance Coverage
Northern Region Southern Region
Question:Where do calls come from?
Answer:
All 16 Counties in Nevada!
MCRT At-A-GlanceHotline Call
• Gather initial information using the Intervention Screening Tool
• Provide support
• Team is dispatched OR
• Refer to community resource (formal or informal)
Mobile Response
• Mental health counselor and psychiatric caseworker travel to youth and family
• Support and stabilize presenting situation
• Perform structured assessments (Crisis Assessment Tool-CAT and Crisis Needs Assessment-CNA)
• Formulate safety plan
• Facilitate hospitalization if needed
Stabilization
• Short-term behavioral health intervention provided in the setting of choice of family (often in-home)
• Facilitate linkage to ongoing community services and supports
• Monitor safety
• Review and update of safety plan
MCRT In Rural NevadaHotline Call
• Call is received on the Las Vegas hotline number
• Call is triaged and Information is gathered-takes about 10 minutes
• The triage person contacts Rural Crisis Team
• Within minutes a Rural Team Member calls the referent and the caretaker to begin the assessment process
Mobile Response
• The Rural Clinician intervenes via Vsee and Case Manager from the Rural community responds in-person or via phone.
• De-escalate crisis
• Perform structured assessment
• Formulate safety plan
• Facilitate hospitalization if needed
Stabilization
• Short-term behavioral health intervention provided in convenient location (often in-home via Vsee)
• Facilitate linkage to ongoing community services and supports
• Monitor safety
Video System• Free• HIPAA compliant• Interactive• Downloadable from any
mobile device, tablets and computers
• Vsee.com
Provider Perspective and SuccessDanielle Gasperini
Division Director of Children's Services,
Director of the Children's Mobile Response Program,
CPC Behavioral Healthcare
Provider Perspective and Success
Prior to the Children’s Mobile Response & Stabilization Program
• There were not many choices for youth when they were experiencing emotional or behavioral challenges.
• Providers provided care in silos.
• Families were told what was best for them and were expected to follow the “treatment plan” with little input.
Provider Perspective and Success Continued…
Prior to the Children’s Mobile Response & Stabilization Program
• Providers were not sensitive to how language impacts the recovery. • Long waits for outpatient care without anything to bridge the gap
often resulted in increased symptoms.• Families were often left to find assistance for their children on their
own with very little support or guidance.• Provider View - Family and Youth Successes
Youth and Family Perspective and SuccessCinaida Anthony, Community Development Coordinator
Ann Goldman, Executive Director
Family Based Services Association
Families in need of immediate support who cannot wait for CMO services have their needs addressed
Families have immediate access to resources, including in-home therapy
Complex families, who will likely be referred to CMO are educated about CSOC quickly, providing a more effective/efficient transition to CMO
Less “bureaucratic” feel to MRSS and families are often more able to actively engage in their journey
Having engaged with families that have MRSS prior to CMO involvement, FSOs are able to help families and CMO establish a working relationship in a shorter time span
Information on NJ FSOs at: https://www.nj.gov/dcf/families/support/support/
Advantages of Family Support Organizations working with MRSS‘Truly, there isn't too much more comforting then someone saying that I get what you are going through. Family Support offers families a unique perspective.’
MRSS Provider regarding FSO Support
Reflections from the NJ CSOC Youth Ambassador“It is crucial to recognize that we cannot control young people, we can only guide them and serve as a support to them. Though they are here with us, these young people, in no way, belong to us. In order to best guide these young people, we cannot take a demeaning or belittling approach. It is simple, when young people feel better, they do better. Just give them hope and inspire their hearts with purpose as you allow them to cultivate their beautiful thoughts.”
“More often than not, young people are literally scorned and sometimes punished for simply being young people- for merely being human. Young people are not allowed to have bad days or moods, they cannot be grumpy or upset, they cannot have disrespectful tones or attitudes. But, how can we as adults experience these very normal responses and feelings each day? No one is perfect and it is important that we remain cognizant that we are not holding young people to a higher level of perfection than we can attain ourselves.”
Gina Pearson, Youth Ambassador for Children’s System of Care
Break
MRSS Panel Discussion:
Two State Perspectives
MRSS Panel Discussion:
Two State Perspectives
Access
Program Model/Response
Assessment and Planning
NJ MRSS Program ResponseDE-ESCALATION – engagement, observing, interrupting and shifting dynamics, education and skill introduction. You are the experts in your youth and family.
ASSESSMENT – strengths, triggers, communication, contexts (medical, mental health, substance use, trauma, development, patterns of behavior, family, collateral outreach, etc.)
PLANNING – safety, crisis and transition, youth and family voice, alternative strategies, plan oversight/progress monitoring
SUPPORT and SERVICE LINKAGE and CONNECTION
NJ Crisis Assessment Tool (CAT)
ChildRisk
Behaviors
ChildBehavioral/Emotional
Needs
Life Domain Functioning
ChildStrengths
Caregiver Needs & Strengths
Trauma, Developmental, Medical, Substance Use and Other Specialty Need Modules
Plan
Clear Plan Goals
Youth and Family perspective on triggers and awareness
Proactive and Reactive Strategies
Concrete Strategies and Resources
Inclusive of Debrief – Opportunity to Learn
NJ Family Safety and Soothing Plan
NJ Individual Crisis Planning: Proactive Plan• Youth and family vision
• Functional strengths of the youth and family
• Target behaviors and primary presenting needs
• Strength-based strategies
• Barriers to implementing strategies
• Additional unmet needs
• Youth diagnosis and medication if needed
• Services to be requested (if any)
• Resource/Support people and their roles
Establish consensus with youth and family on the plan
NJ Stabilization Management: MRSS RoleActive, Engaged, Ongoing Process:
• Additional face to face meetings as needed
• Family liaison and advocate
• Active monitoring of progress toward outcomes
• Resource referrals
• Service delivery oversight
• Transition planning
• Progress notes and other documentation as needed
• Ongoing communication with family
• Collateral contacts
Provider Perspective – AccessWhen a family reaches out to Mobile Response for assistance...
-Family calls 1-877-652-7624
-Greeted by a representative who asks preliminary questions to make sure the caller does not need 911 dispatched.
-Then asked to provide more details about the situation through the use of a triage form to look at that includes:
current risk, previous treatment history, challenges in regard to how they are feeling or acting, changes in typical behavior, any substance use concerns, any concerns with developmental disabilities, life domains explored (school, peers, medical, etc.), caregivers ability to support youth’s needs (understanding of needs, own medical concerns etc.)
Provider Perspective – AccessAfter information has been gathered, the Mobile Response Unit is contacted…
Mobile Response is given a brief summary of the information gathered, access to the shared electronic record for the youth, and patched into the call with the family so a dispatch can be arranged.
• Mobile Response will see the family within 1 hour of the call (up to 24 hours if the family chooses to delay the meeting)
• Safety questions are asked that include:
• How many people will be present at the time of dispatch?
• Are there pets/animals at the location?
• Are there weapons on site? If so, how and where are they stored?
Provider Perspective – AccessWho we see and why we see them...
We see children as young as 2 (although we do not see many in the age range) up to 21.We are called to see youth who:Are showing symptoms of anxiety, depression;
Are bullying or have been bullied;
Have witnessed or been victims of abuse;
Have substance use issues, eating disorders, developmental disabilities, suicidal ideation;
Have experienced the death of a caregiver or loved one, have experienced a traumatic event, have a medical issue that is causing distress;
Are exhibiting aggressive behaviors, are not going to school, have been in trouble with law enforcement…
Provider Perspective – Access The Dispatch
Our Mobile Response Team dispatches in pairs. Why?• Sometimes we need to split up and give the youth and caregiver
undivided attention in order to quell the crisis.
• We like to be able to get everyone’s perspective without the influence of others.
• Sometimes we need to contact emergency services, so one person can stay with the family when we make that call.
• We come prepared to quell the crisis and offer support and linkage.
• We listen to the concerns of both the caregiver and youth and offer strategies that can be utilized right away.
• We create a “safety plan” that identifies supports already in place and brainstorm new supports and strategies.
Provider Perspective – ResponseMobile arrives to see the youth & family…
Provider Safety Plan
• We have a binder that provides information on various symptoms, diagnosis and behaviors.
• We have concrete interventions such as journals, bubbles, items to help distract, door locks, books that speak on different feelings, dry erase boards and timers.
• Informational brochures and handouts of community resources and providers.
• At the conclusion of the dispatch, we also provide the family with a folder that has additional information about our family line, funding, helplines/helplines, HIPPA information, and our local Family Based Services contact information
Provider Perspective – ResponseWe come to the dispatch with resources…
• The first 72 hours after the dispatch is referred to as the “crisis period”… during this time Mobile Response will make follow up calls to the family and check in with them. They will review the Safety Plan with the family and remind the family of our Family Phone Line.
• During this time Mobile Response is able to utilize the initial authorization to dispatch to the family again if needed.
Provider Perspective – Response After the Dispatch…
• If the family would like to continue to receive support from Mobile Response the Stabilization period begins.
• Stabilization can last for the next 8 weeks.
• Mobile Response will link the family to service providers, community resources and provide case management to insure that all providers are communicating and working together.
• Mobile Response has access to: • Intensive In-Community Counselors (IICs) who are able to see the youth and family
in their home or in the community rather than an Outpatient Office.• Behavior Assistances (BAs) who work with the IICs to assist the family with
addressing behaviors.• Mentors who are able to assist the parent and/or youth within the community
master tasks and optimize functioning.
Provider Perspective – Response After the first 72 hours…
• After providing preliminary linkage and resources, Mobile Response will reach out via telephone at a minimum 1x per week to the family, providers, school personnel and other members of the treatment team, if the family and youth provide consent.
Provider Perspective – ResponseAfter the first 72 hours… (cont.)
• While Mobile Response begins discharge planning from the beginning, as we near the end of our authorization period, we insure that the family has a viable plan afterward…
• Possible discharge plans could include:• Outpatient, continued case management, psychiatric evaluation/follow-
up, group therapy, support groups, increased recreational outlets, social skills groups, etc...
Provider Perspective – Response Nearing the end of Stabilization period…
NV Mobile Response
Tools
• Crisis Assessment Tool – Mental health counselor conducts a standardized assessment that includes history, risk behaviors, mental health problems, and functional impairment and aids clinician in judging risk level in key areas
• Crisis Needs Assessment - Psychiatric caseworker evaluates family strengths and needs in social, emotional, medical, educational, and other life domains to provide a holistic approach to support youth and family
• Formulates plan to assist family in accessing needed services and supports
• Recommends referral to Nevada PEP (family run organization) for family-to-family support
Safety Planning
Safety Planning
Safety Planning
After The Assessment: Options For
Safety
1. Facilitate hospitalization
2. Refer back to community providers
3. Stabilization Services If needed and desired, MCRT can offer up to
30-45 days of crisis stabilization services in the family setting of choice (usually in-home)
Designed to ensure safety and kick-start therapeutic progress while facilitating linkage to long-term services and supports
4. No services needed/requested
NV MCRT Where Are Youth Referred Post Assessment?*
*Youth may receive more than one referral
1% 3% 3%7%
15%
61%
14%
No additionalservicesneeded
Familydeclinedservices
Referredwithin DCFS
Referred tonew
communityprovider
Referred toexistingprovider
Referred toMCRT
stabilization
Hospitalized
NV MCRT Current StaffingRural Reno Las Vegas
Clinical Program Manager II 0 1 1
Clinical Program Manager I/Mental Health Counselor III 1 1 3
Mental Health Counselors/Clinical Social Workers 2.5 5 18
Psychiatric Caseworkers0 f/t
25 shared4 f/t
1 intern16
Administrative Assistants 1 1 2.5
Intake Coordinators 0 1 0
NV PEP Family to Family Support SpecialistsAccess both Reno and LV
3 8
Licensed Psychologist 0.25
Financing
Staffing and Supervision
Training and Certification
MRSS Panel Discussion:
Two State Perspectives
NJ MRSS Funding• PRESUMPTIVE ELIGIBILITY
• MEDICAID SPA REHABILITATION OPTION - EPSDT
• STATE FUNDING for YOUTH NOT NJFC ELIGIBLE
• WRAP/FLEX FUNDS to support NON-MEDICAID REIMBURSABLE SERVICES
• TPL coordination
MRSS directly bills Medicaid’s Fiscal Agent, per member per dispatch rate and per 15 minute unit.
MRSS Certification
• Training - First Year and Second Year
• On-line Review
• Core Competency Attestation by Supervisor
Annual Recertification
NV MCRT FundingRural:
• 2016-2019 sub grant through the DCFS/System of Care Expansion Grant
• Division of Public and Behavioral Health manages the sub grant, provides program oversite and case management services
• 2019 + state general fund request with a continued partnership between DCFS and DPBH
In 2015, the Nevada Legislature passed Assembly Bill 292 requiring Medicaid and any health or industrial insurance policy to cover telehealth services to the
same extent as services provided in person. Providers of such insurance may not require the insured to obtain prior authorization for telehealth services.
Urban:
• Funds for a healthy Nevada (Tobacco settlement) 50%
• State general fund 30%
• Federal Funds 20%(Medicaid, Title XX, CMHS/Mental Health Block Grant )
NV MCRT Clinical Oversight
Supervisors review and/or sign off at each step of the process• Every hotline call is staffed
with a supervisor
• Supervisor reviews and signs off on intervention screening
• Staff call supervisor from the field before assigning a disposition
• Supervisor reviews and signs off on safety plan
• Review/supervision of case when staff return from field
Supervisors review and sign off on
stabilization treatment
plans
Occasional live
coaching
NV MCRT Training
Motivational
Interviewing
Trauma Informed Care
(TIC)
Crisis Assessment Tool (CAT)
Crisis Needs Assessment
tool
Trauma Focused CBT
Brief Solution Focused CBT
CSEC EthicsSafety
planningSuicide
awareness
Field Safety training
Cultural linguistics
LGBTQSOC values
and principles
Live training, shadowing,
coaching
System Collaboration
Innovations
MRSS Panel Discussion:
Two State Perspectives
NJ MRSS-Family Crisis Intervention Unit Program Structure
• Combined unit history
• Follows MRSS program model, including access method
• Follows MRSS regulatory standards and FCIU Statute
• Voluntary with the addition of law enforcement and court personnel statutorily able to access MRSS-FCIU Program; must be with the youth and family.
• Ability to petition court
FCIU standalone program available in non-combined unity counties: if no parent/guardian consent, law enforcement and court personnel can refer directly to FCIU
99
NJ MRSS System Collaboration• Screening Centers can:
• Call CSA to connect with CSOC current providers
• request MRSS if youth are not hospitalized
• Initiative with DCP&P: MRSS for every youth placed in a resource home
• MRSS services as part of Station House Adjustment
• Partnering to respond to victims of Human Trafficking
• Ensuring MRSS connection to acute care is supportive to families, systemically (SRC) and on an individual basis
100
Trauma Informed Care in NJDepartment Initiative
• Interventions must address underlying trauma reaction, not focus on surface behavior.
• Mindful of Implicit Trauma Indicators
• Safe, consistent, nurturing environment.
Strengthening Supports for Youth Involved with Child Welfare
• MRSS/Child Welfare Project
• Functional Family Therapy -Foster Care (FFT-FC)
• ARC Grow
Promising Path to Success
• The Six Core Strategies for Reducing Seclusion and Restraint Use.
• The Nurtured Heart Approach®
NV MCRT System Collaboration and Champions
Engagement
Education and training
Building
Support
Collaboration
Nurturing
Communication
Availability
Trust
Parents, neighbors, family, formal family support network
Regional and State consortiums
Hospitals, medical and mental health providers
School Districts
Law enforcement, juvenile justice systems
Faith based, community organizations
Nevada PEP: Family Support ServicesFamily Support:
Nevada PEP’s Family Support Service supports families in advocating for their children with behavioral healthcare concerns.
This national model utilizes the System of Care framework to deliver family driven, youth guided supports and services to increase successful outcomes at home, in school and in the community.
Family Specialists:
Family Specialists have gone through many of the same experiences as the families being served.
All of Nevada PEP’s Family Specialists are family members of children with mental, emotional and/or behavioral health care needs.
Nevada PEP - Family Support ServicesProvide compassion and understanding of the unique experiences and needs of their child and family.
Effective Family Support Components:
Informational/educational support
Instructional/skills development support
Emotional and affirmation support
Instrumental support – concrete service
Advocacy support
Leadership skill building at child and family level and at system levels
Outcomes Monitoring
CQI Approach
MRSS Panel Discussion:
Two State Perspectives
MRSS Quality and Best Practices
Individual Level-Annual Review-Debriefing-Individual Outcome Reports
Provider Level -Data Dashboards-Fidelity Measures
Systems Level-Creative Practice/Success Stories-System Review
CQI ProcessMeasures
• Eligibility process
• Timeliness of services Model
• Appropriate level of care/intensity determinations
• Utilization of services
• Populations serviced within the system
• Provider adequacy
• Youth and family satisfaction
• Clinical and functional outcomes of system care providers
• Assessments of needs of youth referred to CSOC
• Customer service of the CSA108
Assess
Design
ImplementEvaluate
Feedback
MRSS Dispatches - Stabilization - CMO Referrals by Service Area for Previous Completed Quarter
109
0
500
1,000
1,500
2,000
Dispatches Stabilization
Youth in Behavioral Health OOH
1,8241,781
1,860 1,799
1,735 1,623
1,618 1,493
1,363 1,335
1,140
1,0931,000
1,100
1,200
1,300
1,400
1,500
1,600
1,700
1,800
1,900
2,000
MRSS Readmission
30 Day Readmission Rate for youth who transitioned from MRSS between January 2018 and March 2018 was .49%.
Key NJ CSOC Data• Over 52,000 youth authorized for services in the past year
• In 2002, 60% of authorized services were for youth over 14 years old; In 2016, 47% were for youth over 14 years old indicating earlier access and intervention.
• High Family Satisfaction
• Residential Treatment Facility (RTF) length of stay decreased by 25%
• Over 95% of youth accessing MRSS stay in current living situation
• 250% Increase in families accessing MRSS since 2004
• Over 7,000 attendees annually at CSOC trainings
Youth involved with juvenile justice have access to CSOC services
• NJ had 17 county juvenile detention centers - today there are 8
• Decline in juvenile detention average daily population by 60% since 2004
• 6,000 less youth admitted to detention in NJ since 2004
112
NJ’S CSOC Model Impact On Youth We Serve Fewer children in institutional care
Fewer children accessing inpatient treatment
Closure of state child psychiatric hospital and state operated RTFs
Fewer children in out-of-state facilities - currently one child
Children in out of home care have more intense needs than prior to CSOC development
Fewer youth in detention centers
Wraparound model works!
Nationally recognized model for
Statewide Children’s System of Care
NV MCRT Quality
Measures
• Consumer satisfaction questionnaires
• Therapist self-report of use of evidence based practices
Item on stabilization discharge form
• Planning and evaluation unit (internal quality assurance) conducts quarterly chart reviews and provides feedback to program staff
NV Program
Evaluation
Outputs
“What We Did”
Stabilization infoNumber referred, number accepting, number completing, number of sessions, length of
treatment, types of interventions
Referral details
Who refers, referring problems, diagnosis
Call details
Number, type, time of day, date, time to complete screening, time to complete intake, time from call to intake
Demographics
Age, gender, race/ethnicity, location, school info
NVProgram
Evaluation
Outcomes
“How We Helped”Long term outcomes
3 to 4 months post discharge
Client satisfaction 1 week post response
Symptom and functional changeChange in actionable treatment needs (CAT)
Connection to resourcesTherapy, supports, NV PEP
Was safety ensured? Safety planning, need for hospitalization
NV Family Surveys
7 Day Satisfaction
Survey
Long Term Outcomes
Survey
NV Family Surveys
NV Status of Youth at Long Term Follow-
UpTwo to Four
Months Post-Discharge
11%17%
64%
Have visited ERfor Mental
Health
Have had MentalHealth Inpatient
Admit
CurrentlyReceiving MH
Services
Contact Info...Cinaida Anthony
Wyndee Davis
Danielle Gasperini
Ann Goldman
Ann Polakowski
Dayana Simons
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