Comprehensive Children’s Mental Health Systems

KAREN VAN LANDEGHEM: E7 – Comprehensive Children’s Mental Health Systems (GEN) – March 1, 2004

KAREN VAN LANDEGHEM: Good afternoon. I want to thank AMCHP for inviting Illinois to be here and I, I need to say that, actually Barbara Shaw who’s the chair of the Illinois Children’s Mental Health Partnership and the director of the Illinois Violence Prevention Authority sends her regards. She really wanted to be here. I work with Illinois on this initiative; she wanted to be here but because of state budget constraints, needed to stay back in Illinois. So I am, I’m doing this presentation pretty much on her behalf. I am, you’re going to hear some, kind of common themes, I think, and kind of what I, what I say in terms of what Germaine brought up in terms of why Illinois is doing this, at kind of what we’re focused on. I think the difference between our initiative and Kentucky’s is that our, ours focuses on children zero to 18. And probably the other difference is we’re not as old as Kentucky. We just started in 2001. This is a copy of, or a photo of the report that we issued a year ago that is available on the Illinois violence prevention authority website at I did not bring copies of that with me ’cause we have limited copies of this nice version, but you can get it on the website. Just want to give you a little bit of a history about how we got to where we are today. In terms of the Illinois Children’s Mental Health Partnership, it’s important to point out that a lot of the things that even Germaine brought up and others have brought up this morning in terms of children’s mental health and early childhood issues, in particular, Illinois’ been doing a lot of work in that area.

We are, Illinois is a state that just got the ABCD funding initiative. For those of you who are familiar with the build initiative, which is focused on early care and education, Illinois is a build initiative state. And they’re also a state that’s working on the *pew of universal preschool initiative for a limited number of states that are trying to implement universal preschool. So we had a lot to build on in terms of this initiative and especially a lot of work that had taken place with regards to early childhood development. We’re, we’re lucky to have the Chapenhall Center in, in Chicago, also, the Irving B. Harris Foundation for those of you who know that foundation, has put a lot of investment in early childhood issues and also even invested in this. So we’re, we’re really lucky to have those resources in Illinois. Although I will say we are an example of how you can do something with very little money so far. In terms of the history of the Illinois Children’s Mental Health Partnership, in 2001, a task force was established, the Illinois Children’s Mental Health task force, which was kind of prompted by two, two things. A group of child advocates and education leaders produced a white paper on children’s mental health and the schools. And then the social, emotional health committee of the birth to five project, which is out of the ounce of prevention fund and was funded by the Robert Wood Johnson Foundation, which had been doing a lot of work in early childhood development, came together to talk about the, the dire needs that existed within Illinois with regards to children’s mental health.

In 2002, the task force convened by the Illinois Violence Prevention authority issued that report that I was just pointing out. They did that; we did that in nine months. We pulled together nine months to about a year, pulled together a task force, had a, a, a, a group of committees that worked on that and then issued the report with the intent that we wanted children’s mental health to be a priority within Illinois and with, within, with the governor and with the general assembly. And indeed that became a priority, in 2003, the Children’s Mental Health Act passed and where we are today is that we have formed a mental health partnership. The Illinois Children’s Mental Health Partnership, which I’m going to talk about. Some of the key findings that we presented or put forward, which will not be a surprise to many of you here, I’m kind of preaching to the choir, but they were certainly things that were kind of nuggets of information that were useful for us in terms of selling this with the state policy makers in Illinois. But some of the key findings that are outlined in our report are, are the fact that early prevention and intervention efforts can save significant state costs. Many health problems are largely preventable or can be minimized. Children’s social, emotional development is an essential underpinning to school readiness. School readiness for us, and I’ll talk about this in a little bit was kind of a, a rallying issue. It seemed to be the issue that health, education, mental health, all the different sectors could really rally around.

So that was one thing that when we came together as a task force and then as a partnership, we were able to kind of really sell this initiative to the, to the policy makers. We, like, Germaine, had some statistics that were rather startling. There was a study done by the *Ericsson Institute in the University Of Illinois that surveyed childcare providers in Illinois and 42 percent of the childcare providers surveyed, indicated that they had to kick a child out of childcare because they were unable to deal with behavior problems of children. So that was one thing that was kind of part of a catalyst that kind of prompted us moving forward on this. Another statistic that we had, a survey of ten Chicago childcare centers indicated that the childcare providers felt that about 32 percent of their kids had behavioral problems. So like Germaine brought up with their initiative, we saw that, we see the same issues in Illinois, no surprise. One of the big things that we promoted and have talked about is just that we, our initiative’s really trying to reform the mental health system in Illinois and really to try and take resources that are right now, in terms of children’s mental health, devoted towards treatment and try to place a greater emphasis, or an emphasis on prevention and early intervention.

So here were some of the key principles that we advanced and continued to kind of be the principles that guide our work. Again, probably no surprise to you, a successful children’s mental health system engages families and caregivers. Prevention and early intervention should start early, beginning at prenatal and at birth and continue throughout adolescence and even we are talking about even transitions to adulthood, so we talk about even the, up to 21 and even beyond. Public and private resources had to be maximized and coordinated and that children’s mental health services should be delivered in natural settings. I should mention that in terms of that task force and, and still today, but we had about a hundred participants on the task force in terms of representing everything from juvenile justice, child welfare, education, health, really array of both state agency representatives, community based organizations, providers, family members, so kind of, I’m sure if you have similar issues in your state, we really had a range of, of involvement. And what we did is kind of put together some priority recommendations that we took to the legislature and to the governor last year and, and were kind of the formulated or part of that Children’s Mental Health Act that got passed.

One of our priority recommendations out of a long list of recommendations that are in that report, that report must have, I should’ve counted them up but it’s probably four pages worth of at least, of recommendations. We, we selected some priority recommendations that the, we then advanced within Illinois and really tried to integrate into the Children’s Mental Health Act, those where we needed, felt like we needed some legislation to, to move things forward. One of it was just the fact that we needed to make children’s mental health a priority in Illinois and part of that was to develop a mental health plan much like Kentucky. We are wanting to develop a plan that will kind of be a five to ten year plan for how we can reform children, the mental health system in Illinois to support children and their families ages zero to 18 for kids. We created the, we recommended that we create a children’s mental health partnership that reports directly to the governor and that in fact has come to fruition. And another big priority for us and I think this is kind of unique is that we put a straw in education, in addition to the health focus that we have and a lot of health work we’re doing, public health work we’re doing. We have a strong emphasis on education as well.

And part of our recommendations and part of, what was part of the Children’s Mental Health Act that is now law, is that the state education agency’s required to develop a plan to incorporate social, emotional learning standards as part of the Illinois learning standards. And so for those of you who are familiar with your education agency counterparts, you know that learning standards help drive what gets measured in states. And so this was an important thing we felt, and actually the educators were behind this, surprisingly. I mean sometimes educators don’t want yet another thing added on to the education system, but they were very much behind the importance of social, emotional development, incorporating this into the state early learning standards. A big thing for Illinois, no surprise to many of you, I’m sure, is just a need to maximize current investments. We are a state with, I forget, how many billion dollar deficit right now so we are a state with very little funding so it was important to kind of both promote this to maximize current investments and invest sufficient public and private resources over time. That included Medicaid and our Kid Care, which is our SCHIP program. Promoting investment in mental health services in all systems that affect children. And then strengthening the financing of children’s mental health services within the office of mental health.

The office of mental health, which is our state mental health authority at the time, and that got changed as a result of the legislation, they were only allowed to use funding for children ages three to 18. And so we changed the, through the legislation changed that to allow, it’s not an entitlement, but to allow our state office and mental health to support programs for kids zero to 18. I’m not gonna go through all of these recommendations, but just to give you a flavor of kind of what we recommended to the governor. And through that report and also to the general assembly, qualified and adequate, we adequately trained work force, both professional preparation, certification requirements, and also, professional training and education was a priority. Public awareness campaign was and still is a big focus of this initiative. We in fact now have as part of the Children’s Mental Health Partnership, which grew out of this task force, a committee just on public awareness alone. People felt that is was really important that in order for us to continue to get buy in for this issue, that there needed to be public awareness around reducing the stigma with regards to mental health in the state.

Another unique thing to our initiative, which came out of the recommendations and nothing has really happened yet, but we really are trying to push a children’s mental health research and resource center, or centers. In, in other words, a, there’s a real need for evidence based practice and trying to incorporate that into the system, both in the children’s mental health system, but also within public health. So this again was a big priority of both the task force and now the partnership. So here’s the Children’s Mental Health Act Of 2003, just to highlight it for you. This was passed in April of 2003, it was a result of the report that came out and it took the children’s mental health task force that was in place and, and made it, kind of into a partnership. It mandates that this partnership, develop a children’s mental health plan, as I mentioned it, allows the office of mental health to, funds to be used for children zero to 18. It requires the state board of ed to do the social, emotional learning standards. It also requires all Illinois school districts to develop policies on social and emotional development. So here again, yet another focus on education and a, and a area of emphasis for us. And we felt that there were some things that Illinois could do to improve our methods of capturing Medicaid funds that could be used to support children’s mental health and so that’s also within the legislation.

I, in the interest of time I won’t go through all of this, there’s just part of the plan, there’s some key elements of the plan, there are, that kind of, or mirror what’s in that report that’s on our website. But, you know, just to give you a sense, we, the plan is going to be due, preliminary plan will be due to the governor in September of 2004 and then a final plan will be due in December. And that’s gonna really be the blueprint or kind of the detailed action plan for our further work in this area. Some of the things that we are doing right now, I’m going to skip ahead, here’s our partnership priorities and, and all of those elements of the plan are in your handouts and I have those out at the table. So our partnership priorities right now are to prepare and submit this plan as I mentioned to the governor and the general assembly. We are working very hard with the state education agency to develop and distribute school policy format, guidance and technical assistance to school districts. As a result of that legislation, school districts are required to submit their policy to the state by August 31st.

So we had to really ratchet it up very quickly to try and get some information out to the school districts that, that, that this was a requirement, first of all, and that also we are gonna be developing a lot of technical assistance over the next two or three months to try and just give them some further guidance on what they might want to think about. We are really trying to emphasize the fact that we see this as not expecting a Cadillac version of the school policy from schools. We envision that the partnership, working with the state education agency, the public health department will be working with schools to provide them technical assistance on how to develop these school policies and, and strengthen them. So that’s going to be the focus and the emphasis of working with schools. Our, another big priority is developing a plan in guidance for public awareness campaign. We actually, there are four committees that are part of the Children’s Mental Health Partnership now. One of them is a public awareness committee and we are actually going to be seeking funds to try and get some funding to do public awareness throughout the state. And I’m going to talk a little bit about the pre-hospital screening process, which is one of the things that is a, a positive outcome of the Children’s Mental Health Partnership in this task force.

Just real quickly, our partnership structure, it’s smaller than the task force, the task force was kind of an open task force that had about a hundred members on it. The partnership structure, because of state regulations and the way this governor, gubernatorial body exists, it only has 25 members, they’re appointed by the governor, plus state agency participation. So public health, education, mental health, social services, juvenile justice, corrections, child welfare, they’re all at the table, in addition to the 25 members who are on the partnership. It has an executive committee structure and then we formed four standing committees. And there was a little bit of a debate about whether we focus this on prevention, early intervention and treatment, which is how we are viewing the system with a focus more on prevention and early intervention, do we focus our committee on that or do we focus it on the population and we chose population just to make sure that there was enough depth in these areas. So we have four standing committees, early childhood, school age, school policies and standards and then public awareness. And each committee is charged with kind of assuring that there’s some common threads that they look at across the committees.

So family involvement, cultural competency, there’s some things that we’ve given to committees to make sure they address so that there’s that cross threading, if you will. So what are some of our early successes? Excuse me. We got broad support and buy in, in, in my view, in a very short amount of time. This was not a very hard thing to sell both to the legislature or to the governor, governor *Blegoiavitch or to even the, the general public. There’s been a lot of real support for children’s mental health. I think it’s something that crosses all economic backgrounds in terms of people who are struggling with different issues. So we really got a lot of broad support and buy in early on. There was broad consensus that the system needed reform. In Illinois it’s, I, I think a really interesting thing about this initiative and, and, and kind of testimony to how supportive people were is that, I think that children’s mental health is grossly under funded in terms of treatment already. There’s not a lot of emphasis on children’s mental health in terms of the dollars that go to states and then go to communities in terms of the treatment end. And so what you could possibly run up against are people saying, well, if you focus on prevention and early intervention, you’re gonna take away needed dollars for treatment that we already are under-resourced and fragmented.

And we really as a state have really rallied the troops, if you will, to really get behind this initiative and to recognize that there are, yes, there needs to be more dollars for treatment for children’s mental health, but that prevention and early intervention are really the way to go. And that really wasn’t an issue. It kind of came up a little bit a few times when we first began this, but it really has not been an ongoing issue. So there was broad consensus that the system was fragmented and really needed reform. I think another success was the passage of the Children’s Mental Health Act, which included those changes to the *one way learning standards, the changes to the school districts requiring that they have policies. And also changes to how, and I’m not sure how other states do this, but in Illinois, how children were screened, those who needed treatment of the pre-hospitalization screening process and as it related to Medicaid. And that is called the screening assessment and support services system. In Illinois, this is a system where children who do need treatment get screened. It’s been in existence for 15 years and the Children’ Mental Health Act required that the screening assessment of a child prior to any Medicaid funding, funded a mission to an in-patient hospital for psychiatric services take place.

They were already doing a screening, but this is kind of more consistent screening, it’s a one stop shopping screening, if you will. And so this became one of the outcomes of the Children’s Mental Health Act and I, if you have questions about this screening process, I’m gonna refer you to somebody else within the office of mental health. But this is one of the things that was an outcome of this initiative already. And in a, in one year’s time, the unique thing about this, I think is that the Department Of Human Services in Illinois, children of family services and Department Of Public Aid, or our Medicaid agency all rallied around to really change the system, make it much more family friendly, much more family focused. What it does, is it puts the emphasis in providing services in the least restrictive environment with a focus on really trying to see if there’s alternative services within the community and not require hospitalization for a child, trying to reduce the length of stay, and more community based integrated services. They’re also taking this program, and this is a little bit of a hot topic right now, and changing it from a grant based screening program to a fee for service.

So you can imagine we’re having some difficulties with that, with that change, but we’re confident that it’s going to result in a, in a really reformed system that will be much more improved. This was a good system but we feel like there was some improvements that could be made. So what was the title five role and involvement? And I was hoping Steve Saunders was here so he could add and I could pick on him, but it doesn’t look like he’s here. Just wanted to highlight, really the, public health has been a part of this from the beginning, they’ve been a part of the initiative, they’ve been a part of the partnership and they’ve actually been doing a lot of investing already in early childhood issues and school issues from home visiting programs to healthy families, any of those things we kind of connect to and link with mental health. More specifically related to this initiative, they’re a member of the task force and partnership and they are promoting and linking, promotion and linkages of related activities. Including, right now, they are funding pilots to link childcare and community health systems through the childcare resource and referral agency system so that there are, I believe, three pilot sites, where there’s a mental health consultant that works directly with childcare providers.

So that’s one thing that title five has been doing. They are doing training for all of their health department providers and how to conduct social and emotional develop screenings for children in their system. And one thing that they’ve just begun, it’s still kind of in the early stages, is working with the office of mental health to strengthen behavioral health care referral system for primary care providers. So briefly, what are some strategies that we believe worked? And I think these are things for those of you who don’t have this kind of initiative yet, going on in your state and are thinking about doing it. Some of the things that have been really successful for us, of course, we built it on the research, national, state, best practices, folks like Kentucky and Vermont. We called Minnesota, California, there’s a lot of states that we benefited from because of their work in this area. So research, also that, and the research that was done by the Ericsson Institute that talked about the childcare providers and their concerns with behavioral issues, all that really helped us in terms of advancing this issue. We really ensured that the issue was framed to capture multiple sector buy-ins.

So again, as I mentioned earlier, school, for us, school readiness was really that, one of the key things, not the only one, but one of the key ways of framing this, it really was able to kind of get the education system involved, mental health, public health. The fact that we also put an emphasis on improved health and well being, and also that we didn’t let go of the mental health treatment piece as I mentioned earlier. There were some who were concerned that if we started talking and promoting about prevention and early intervention, that resources might be taken away from an already under-resourced treatment system. And that really did not, was not a real big issue for very long. One of the other things that we did is we identified real world stories, the, actual stories for use in the report that we did. And then we used those stories with policy makers to talk about the severity of the problem and we also have positive stories. We have stories about, success stories as well. So those were really helpful for us in terms of trying to sell this to the Illinois general assembly and others. And I should remind you and it’s, I think we’re all in this place in states, and we did this in a very tough budget time, both, it was just done last year.

So we were able to get this legislation passed and support for this, a new initiative in what is really a very rather dire budget environment within Illinois. So I think that’s another example of some success that we had. One of the, another strategy that worked is that we had full task force input to the report and sign off on the report. We really made sure that we had a process where everyone could provide input to that report, provide input to the recommendations of the report, and were maintaining that type of process in terms of the children’s partnership that we have in existence now. And also in terms of the plan that we’re going to be submitting to the governor in September. Another strategy that worked is that we identified priority recommendations. As I mentioned earlier, we probably have 50 or so recommendations that were included in that report. It was really important to identify priority ones. Ones that we felt were important, ones we felt that needed to be done immediately, ones that also we felt that the policy makers, state legislators would be able to embrace and that was really an important part of a, of getting the Mental Health Act passed, but also the initiative passed.

We identified potential areas of cost saving for the state, we had to assure that the legislation was budget neutral and we also found and engaged members and key change agents who could serve multiple functions in the partnership. And an example of this is a school principle who was implementing a social, emotional develop curriculum in her school, whose son also happens to be a state legislator. So it, and she now is the co-chair of one of the committees. So this was a really, she’s a wonderful, wonderful person, really understands these issues, understands it from a public health perspective but is in, is a school principle. And I think it’s those kind of folks who have been really, especially instrumental in this initiative because she can really speak to the issues from seeing them in her school, but then also can talk to her son when, whenever we need her to. So what are some challenges and, and solutions? And I need to wrap this up, but I think one big challenge is moving from broad recommendations to concrete action steps. Again, we have these 50 recommendations and we’re really trying to hone in on what are those ones we want to do in the next two years in terms of changing the system.

We are working with a, a committee structure and I think we are trying to be very organized about how we do that so that we can show outcomes really quickly and also make sure that we’re very task oriented. I think another challenge is maintaining momentum and we are trying to do that with meetings and how we’ve set up the initiative. Assuring buy, buy-in, we will be holding public forums this summer once we develop the action plan, or the action steps for this plan, we are going to be taking those out on the road to get input around the state. Finding a place for all stakeholders. We were only allowed to have 25 members on the partnership and we, you know, recently got a call from one of the senior level judges in Cook County who is very interested in this initiative and wanted to be involved. And so what we did is formed an ad hoc advisory group to the partnership to make sure that we could involved as many people as we could. And, and he’s clearly a very senior person, so we’re trying to use it in an ad hoc way to make sure we tap him, but also keep him involved. And also I think finally is to seeing accomplishments and our big solution here is just to prioritize, prioritize, and prioritize in terms of the recommendations.

I just want to close with, I guess another few challenges that I didn’t put up here, which are kind of some of the biggest ones, are doing this in the current budget environment that we have. It, it’s a tough budget times for all of us and how do you do this when clearly we’re, we’re seeking funding right now for a lot of this work. We want to do some pilots around the states, we want to do technical assistance, we want to get very concrete about some of the outcomes in the state. And so it’s a, it’s a hard time to be doing this kind of work, but the good news is that it’s very supported by many people. I think another big challenge is just shifting this system from a system that’s focused on treatment, largely in terms of children’s mental health to one that’s focused on prevention. And how do you do that and how do you do that at the local level in terms of community mental health boards and authorities and those working with public health. And we haven’t, I’ll be honest, haven’t figured that out yet. We’re still going to be doing that work forthcoming. And I also will, will close by just putting in a commercial that or a, a plea that I think I really want to commend the maternal and child bureau for their investment in the early childhood initiative. I think, you know, from, from a state hat on, we need more of those investments. There’s, there’s not a lot of investment in terms of prevention. I believe in terms of when you look at funds that are available to states for prevention and so I think my, my plea is that we continue to need to have that kind of leadership both from the bureau and groups like the Common Wealth Fund and others for this kind of work. Thank you.