acute mental health care services for children in pinellas county (florida) annette christy, ph.d....
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Acute Mental Health Care Services for Children in Pinellas County (Florida)
Annette Christy, Ph.D.
John Petrila, J.D., LL.M
Kristen Hudacek, Psy.D.
Diane Haynes, M.A.
Department of Mental Health Law and Policy
Louis de la Parte Florida Mental Health Institute
Community Partner
Personal Enrichment Through Mental Health Services
Thomas Wedekind, ACSW
Anne Pulley, B.S.
This project was funded by the USF Collaborative for Children, Families and Communities with Funds from the Pinellas County Juvenile Welfare Board
The Pinellas County specific archival data analyses were made possible by the Pinellas County Data Collaborative
Portions of the Baker Act data processing and entry were funded by a National Institute of Mental Health Grant to Paul Stiles (R01MH060217)
Acknowledgement
The burden of suffering experienced by children with mental health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.
The Report of the Surgeon General’s Conference on Children’s Mental Health, Satcher, 2001, p. 3
Study Components
Review of records for 35 children who had a recent Baker Act examination
Archival Database Analysis
–Statewide•Analysis of Baker Act Data
•Analysis of Medicaid and FL Department of Children and Families claims data
–Pinellas County•The above sources, plus…..
•Additional data sources available via the Pinellas County Data Collaborative
Baker Act Examinations
The Baker Act is the term applied to Florida’s civil commitment statute
Individuals can undergo a short-term, involuntary psychiatric or “Baker Act” examination of up to 72-hours if:
–The are a person with mental illness
–There is evidence of harm to self, harm to others and/or self neglect
Examinations may be initiated by:–law enforcement officials
–mental health professionals
–judges
Individuals are examined in ~115 Baker Act Receiving Facilities that are designated by the Florida Department of Children and Families
Baker Act Reporting Center
Legislative reforms were implemented in 1996 in response to elder abuse related to Baker Act examinations
A form documenting each examination was required to be sent to the Florida Agency for Healthcare Administration
FMHI agreed to serve as the repository for these data and has been receiving data from 1997 to present
These are data on short-term examination (not longer term commitment)
Florida is the only state to have a central repository of client level data on short-term, involuntary psychiatric examination
Baker Act Data
From 1997 to present the Baker Act reporting center has received over ½ million Baker Act examination forms.
We currently receive over 100,000 forms annually
This represents approximately 430 forms received on average every business day
Approximately 16% of forms received are for examinations of children~80,000 forms received documenting examinations for children from 1997 through 2002
~17,000 forms documenting examinations for children likely received in 2003
Volume of Baker Act Data
0
20,000
40,000
60,000
80,000
100,000
120,000
1997 1998 1999 2000 2001 2002 2003
Calendar Year
# of forms received
•1997: 69,235
•1998: 73,900
•1999: 78,064
•2000: 83,989
•2001: 95,900
•2002: 105,046
•2003: ~109,000
Percentage Baker Act Data Adults vs. Children Statewide
0%
20%
40%
60%
80%
100%
2000 2001 2002 2003
Calendar Year
AdultsChildren
Data for children represented 15-17% of the data received in the past 3 and a half years
Record Reviews
•35 Children from the PEMHS Crisis Stabilization Unit
•Parent/Guardian Consented
•Children Assented (only after permission from parent/guardian to approach child)
•First two months focused on consenting only children in the foster care system
•Due to time and cost constraints, then attempted to consent/assent every child
•Review of PEMHS record for the Baker Act examination from which the child was recruited into the study
Record Reviews
40% (n = 14) of children had a history of abuse•26% (n = 9) sexual abuse
•23% (n = 8) physical abuse
•11% (n = 4) emotional abuse
The most common presenting problem was suicidal ideation/gestures (n = 19; 54%)
Just prior to their examination 80% of children (n = 28) were living with family
Children had between one and four Axis I diagnoses (Mean = 2.31)
Record Reviews - Diagnoses
Diagnosis N %
Adjustment Disorder 15 42.86
Depression 15 42.86
Oppositional Defiant Disorder
9 25.71
Conduct Disorder 8 22.86
ADHD 8 22.86
Bipolar Disorder 7 20.00
Intermittent Explosive Disorder
6 17.14
Post Traumatic Stress Disorder
5 14.29
Dysthymic Disorder 4 11.43
Anxiety 1 2.86
Psychosis 1 2.86
Schizoaffective Disorder 1 2.86
Record Reviews
The most common referral sources were:•Police 34% (n = 12)•Medical Facilities 34% (n = 12)
Record Reviews
The most common referral sources were:•Police 34% (n = 12)•Medical Facilities 34% (n = 12)
43% (n = 15) had past or current justice system involvement
Record Reviews
The most common referral sources were:•Police 34% (n = 12)•Medical Facilities 34% (n = 12)
43% (n = 15) had past or current justice system involvement
46% (n = 16) had past or current substance abuse documented
Record Reviews
The most common referral sources were:•Police 34% (n = 12)•Medical Facilities 34% (n = 12)
43% (n = 15) had past or current justice system involvement
46% (n = 16) had past or current substance abuse documented
Insurance Status•51% Private Insurance•26% Medicaid as Primary (6% as Secondary)
Record Reviews
The most common referral sources were:•Police 34% (n = 12)•Medical Facilities 34% (n = 12)
43% (n = 15) had past or current justice system involvement
46% (n = 16) had past or current substance abuse documented
Insurance Status•51% Private Insurance•26% Medicaid as Primary (6% as Secondary)
63% Receiving TANF benefits at time of exam
Record Reviews - MedicationsMedication N % Medicatio
nN %
DDAVPdesmopressin acetate
11 31.43
Zyrtec 1 2.86
Trileptal 9 25.71
Zantac 1 2.86
Risperidal 9 25.71
Wellbutrin
1 2.86
Lexapro 8 22.86
Prozac 1 2.86
Zoloft 6 17.14
Prolixin 1 2.86
Depakote 6 17.14
Lithobid 1 2.86
Strattera 4 11.43
Haldol 1 2.86
Paxil 4 11.43
Effexor 1 2.86
Pamelor 4 11.43
Cogentin 1 2.86
Tenax 3 8.57 Avitan 1 2.86
Seroquel 3 8.57 Atenolol 1 2.86
Vistaril 2 5.71 Abilify 1 2.86
Desyrel 2 5.71
Record Reviews – Baker Act Data32 children had ssn’s necessary for identification of Baker Act Data
These 32 children had 56 examinations over a period of almost three years
Record Reviews – Baker Act Data32 children had ssn’s necessary for identification of Baker Act Data
These 32 children had 56 examinations over a period of almost three years
Certificate Type57% (n = 32 exams) Law Enforcement41% (n = 23 exams) mental health professional2% (n = 1) judge
Record Reviews – Baker Act Data32 children had ssn’s necessary for identification of Baker Act Data
These 32 children had 56 examinations over a period of almost three years
Certificate Type57% (n = 32 exams) Law Enforcement41% (n = 23 exams) mental health professional2% (n = 1) judge
Evidence Type88% (n = 49) Harm 2% (n = 1) Harm and Neglect 9% (n = 5) Neglect 2% (n = 1) No Evidence type
Record Reviews – Baker Act Data32 children had ssn’s necessary for identification of Baker Act Data
These 32 children had 56 examinations over a period of almost three years
Certificate Type57% (n = 32 exams) Law Enforcement41% (n = 23 exams) mental health professional2% (n = 1) judge
Evidence Type88% (n = 49) Harm 2% (n = 1) Harm and Neglect 9% (n = 5) Neglect 2% (n = 1) No Evidence type
Harm Type 66% (n = 33) harm to self 24% (n = 12) harm to self and others 8% (n = 4) harm only
Record Reviews – Baker Act Data32 children had ssn’s necessary for identification of Baker Act Data
These 32 children had 56 examinations over a period of almost three years
Certificate Type57% (n = 32 exams) Law Enforcement41% (n = 23 exams) mental health professional2% (n = 1) judge
Evidence Type88% (n = 49) Harm 2% (n = 1) Harm and Neglect 9% (n = 5) Neglect 2% (n = 1) No Evidence type
Harm Type 66% (n = 33) harm to self 24% (n = 12) harm to self and others 8% (n = 4) harm only
Repeated Examinations1 exam 38% (n = 12) 5 exams: 3% (n = 1)2 exams: 13% (n = 13) 7 exams: 9% (n = 3)3 exams: 6% (n = 2)4 exams: 3% (n = 1)
Archival Database Analyses
1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence
Archival Database Analyses
1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence
Repeated Examinations1 exam: 67% 4 exams: 3%2 exams: 18% 5 or more: 5%3 exams: 6%
Archival Database Analyses
1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence
Repeated Examinations1 exam: 67% 4 exams: 3%2 exams: 18% 5 or more: 5%3 exams: 6%
Gender: 50% Male Age: Average age at time of first examination = 13.60 years
Archival Database Analyses
1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence
Repeated Examinations1 exam: 67% 4 exams: 3%2 exams: 18% 5 or more: 5%3 exams: 6%
Gender: 50% Male Age: Average age at time of first examination = 13.60 years
Certificate Type62% Law Enforcement33% Mental Health Professional 4% Judges
Archival Database Analyses
1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence
Repeated Examinations1 exam: 67% 4 exams: 3%2 exams: 18% 5 or more: 5%3 exams: 6%
Gender: 50% Male Age: Average age at time of first examination = 13.60 years
Certificate Type62% Law Enforcement33% Mental Health Professional 4% Judges
Evidence Type89% Harm Only5% Neglect Only4% Both Harm and Neglect1% Evidence Type Missing
Baker Act Exams for Children in 2002 – By Month
Statewide
0200400600800
1,0001,2001,4001,6001,800
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Pinellas County Cross System Analysis
Data Set Label General Description of Data
Baker Act BA A statewide database containing information about short-term, involuntary psychiatric examinations
Child WelfareData only available from July 1999 to Nov 2000
CW A statewide databases containing child (only) information on abuse allegations and demographics (founded/unfounded investigation, type of abuse and results or actions taken)
Emergency Management System
EMS Pinellas County-wide emergency medical service information system containing demographic and situational information on 911 calls where ambulance was sent out, whether or not someone was transported via ambulance.
Department of Children and Families Integrated Data System
IDS An automated data system of the Florida Department of Children and Families containing information about alcohol, drug abuse & mental health services at state funded providers.
Medicaid Claims
MDC A statewide database containing Medicaid physical and Mental health claims data
Pinellas County Cross System Analysis
The majority of children with a Baker Act examination in the three fiscal years also had data in one of the four other data systems
18% - only Baker Act data 8% - 3 other data systems
31% - 1 other data system 14% - 4 other data systems
29% - 2 other data systems
N CW IDS MDC EMS
All Children 1,559 27.33% 72.61% 40.99% 27.33%
Girls 778 31.75% 68.51% 38.43% 31.75%
Boys 781 22.92% 76.70% 43.53% 22.92%
Archival Analyses – IDS DataFiscal Years 1999, 2000 and 2001
Pinellas Statewide
41% 40% Crisis Support/Emergency
41% 35% Crisis Stabilization
18% 42% Medical Services
18% 36% Outpatient Individual
18% 19% Treatment Alternatives for Safer Communities
17% 34% In Home and Onsite Services
16% 40% Case Management
6% 25% Assessment
6% 6% Substance Abuse Detoxification
5% 17% Intervention
5% 2% Intensive Case Management
Archival Analyses – Medicaid Data Fiscal Years 1999, 2000 and 2001
% Children w/ Service Cost and % of Total CostPinellas Statewide Pinellas Statewide
TOTAL COST FOR 3 YEARS $8.2 M $208 M
78% 61% Counseling Therapy and Treatment Services $505,000 $6.5 M 5.2% 3.1%
76% 65% Evaluation and Testing Service $155,000 $3.6 M 1.6% 1.8%
74% 57% Treatment Planning and Review $113,000 $1.7 M 1.2% 0.8%
45% 39% Targeted Case Management $1.7 M $22.8 M 17.6% 11.0%
40% 36% Children’s Behavioral Health $1.2 M $16.9 M 12.1% 8.1%
36% 28% Child Ancillary Inpatient Services $75,000 $1.8 M
0.8% 0.9%
Archival Analyses – Medicaid Data Fiscal Years 1999, 2000 and 2001
% Children w/ Service Cost and % of Total CostPinellas Statewide Pinellas Statewide
34% 21% Hospital Outpatient Mental Health Services $96,000 $1.8 1.0% 0.9%
33% 39% Physician’s Services $24,000 $497,000 0.3% 0.3%
26% 28% Child Inpatient Care ` $1.7M $50.0 M 17.8% 24.1%
26% 17% Other Mental Health $74,000 $894,000 0.8% 0.4%
25% 22% Emergency Mental Health Services $18,000 $1.0 M 0.2% 0.5%
24% 21% Physician’s Services Clinic or Outpatient $16,000 $497,000 0.2% 0.2%
Archival Analyses – Medicaid Data Fiscal Years 1999, 2000 and 2001
% Children w/ Service Cost and % of Total CostPinellas Statewide Pinellas Statewide
19% 37% Lab with Mental Health Diagnosis $4,400 $376,000 0.1% 0.2%
17% 20% Rehabilitative Services $115,391 $2.7 M 1.2% 1.3%
13% 13% Behavioral Health Overlay Services $608,057 $10.3 M 6.3% 5.0%
10% 16% Day Treatment Services $154,478 $6.3 M 1.6% 3.1%
6 % 5% Therapeutic Foster Care $1.5 M $22.3 M 15.9% 10.8%
6% 4% Substance Abuse Inpatient $156,368 $35.0 M 1.6% 1.7%
Key Finding #1 – System Findings
Multiple programs are accessed by children at PEMHS
The type and timing of the services are based on factors such as whether children are in the dependency system, their legal status (voluntary vs. involuntary), their needed level and type of care, and availability of services
Interaction of staff from PEMHS and from the Family Continuity Program (FCP) is key to the access and continuity of care for some children
Key Finding #2 – Certificate and Evidence Type
Baker Act examinations of children were more likely to be
initiated by law enforcement officials and to be based on
evidence of harm than examinations for adults, suggesting
that a focus on factors related to law enforcement initiated
Baker Act examinations would help us to better understand
examinations of children and associated factors
Key Findings #3 - Seasonality
The number of Baker Act examinations for children was less in
the summer, both statewide and for Pinellas County
Although cause and effect cannot be determined from this
correlational finding, they suggest some seasonality in Baker Act
examinations for children and is highly suggested that school is
involved in this seasonality
Key Findings #4 – Repeated Examination
Thirty-three percent of the children with a Baker Act examination over a three-
year period in Pinellas County experienced more than one examination during
this time period
Focused attention on this subset of children with multiple involuntary
examinations is warranted, given that the purpose of crisis stabilization units is
to offer emergent care – not the longer term care that may be needed by many of
these children
Multiple examinations may suggest discontinuity of care
Additional focus on this subpopulation could yield information about the causes
of repeated examinations and ways to intervene to prevent them
Key Findings #5 – History of Trauma
The finding that 40% or the children from the case studies
had experienced sexual, physical and/or emotional abuse
suggests that trauma is an important factor to address when
planning and implementing care for some children who
receive acute mental health care
Key Findings #6 – Therapeutic Foster Care
The 41 children who experienced at least one Baker Act examination over a three-year period in Pinellas County who also had Medicaid reimbursed therapeutic foster care accounted for 6% of the children with Medicaid reimbursed services, but their therapeutic foster care reimbursed care of over $1.5 million accounted for almost 16% of the cost of Medicaid reimbursed services
Almost 5% of children statewide with at least one Baker Act examination over a three-year period had Medicaid reimbursed therapeutic foster care services, at a cost of over $22 million representing almost 11% of Medicaid reimbursed services
The high cost of these services for a relatively small number of children, particularly in Pinellas County compared to statewide, suggests that a focus on healthcare needs for children in this group may be warranted
This may be particularly important within the current context of privatization of foster care across Florida and the focus on integration of the foster care and behavioral health care system
Key Findings #7 – Intensive Case Management
o The use of case management and intensive case management is lower than we expected for the population of children who had contact with the involuntary, acute-care system
For example:
At least one case management claim over three years:• 16% Pinellas• 40% Statewide
At least one intensive case management claim over three years:• 5% Pinellas• 2% Statewide
Contact Information
Annette Christy - [email protected] - 813-974-7419
FMHI: http://www.fmhi.usf.edu
Baker Act Reporting Center: http://bakeract.fmhi.usf.edu
Click on “Documents” link to go to page with pdf file of complete report
Collaborative for Children, Families and Communities: http://usfcollab.fmhi.usf.edu/