Center for Mississippi Health Policy

An Interagency Solution for Mississippi’s Children

The state statute (§43-14-1 ff.) that establishes and governs the Interagency System of Care for children and youth with serious emotional/behavioral disorders sunsets July 1, 2010. The Center for Mississippi Health Policy commissioned Mr. Cliff Davis of the Human Service Collaborative to conduct an assessment of the current system and provide recommendations for strengthening the system. This Issue Brief provides an overview of the Assessment and Study of Mississippi’s System of Care. The full study report and executive summary can be found at the Center’s web site: www.mshealthpolicy.com.

What is a System of Care?

A System of Care is “a coordinated network of community-based services and supports that are organized to meet the challenges of children and youth with serious mental health needs and their families.”¹   The System of Care model represents an interagency, multi-disciplinary approach to care for children and youth with serious emotional disturbances and their families.  It includes a full range of accessible mental health and other necessary services that are timely, intensive and in the communities where the children and youth live. Without appropriate treatments and supports, these children and youth perform poorly in school, have high drop-out rates, and frequently end up in the juvenile justice system—all factors that contribute to the range of parents’ emotions of concern, exhaustion, frustration, and hopelessness.

The System of Care model was designed for states to address factors that contribute to these issues:²

• Children with behavioral problems were not getting the services they needed,
• Services often were provided in restrictive out-of-home settings,
• Few community-based services were available,
• Service providers did not work together,
• Families were not involved adequately in their child’s care, and
• Cultural differences rarely were taken into account.

Figure 1 shows that Mississippi’s System of Care framework is organized around several overlapping dimensions.³ 

Development of Mississippi’s System of Care

Mississippi was one of the first states in the nation to create foundations for systems of care through statute.  In 1993, SB 2626 was passed during the Mississippi Legislative Session, creating the Children’s Advisory Council in §43-13-117 of the Mississippi Code.  The legislation mandated pilot projects at the community level to test the effectiveness of planning and intensive case management services for emotionally disturbed or mentally ill children and youth who needed multi-agency services.  The Children’s Advisory Council consisted of one member from the State Department of Health, the Department of Human Services, the State Department of Mental Health, the State Department of Education, and the Division of Medicaid, as well as a representative of Mississippi Families as Allies.  The legislation stated: The Children’s Advisory Council shall oversee a pool of state funds contributed by each participating agency that currently expands funds and care for the children and youth who are to be served by this act.  The goal was to use the pooled funding at the local and state level to better serve those children and youth.

This legislation was reauthorized in the 1996, 1998, and 2000 Mississippi Legislative Sessions.  In 2001, HB 1275 was enacted, with the Mississippi Legislature establishing a statewide System of Care, with local Multidisciplinary Assessment and Planning Teams (MAP Teams) around the state.  To improve interagency partnerships for serving the youth and children, HB 1275 also created the Interagency Coordinating Council for Children and Youth (ICCCY) stating: The ICCCY shall consist of the following membership: (a) the State Superintendent of Public Education; (b) the Executive Director of the Mississippi Department of Mental Health; (c) the Executive Director of the State Department of Health; (d) the Executive Director of the Department of Human Services; (e) the Executive Director of the Division of Medicaid, Office of the Governor; (f) the Executive Director of the State Department of Rehabilitation Services; and (g) the Executive Director of Mississippi Families as Allies for Children’s Mental Health, Inc. (§43-14-1(2) Mississippi Code, 1972 Annotated). ICCCY is required to meet at least twice annually, lead the development of the statewide System of Care, oversee the annual pool of funds for the System of Care, and monitor the performance of MAP Teams.

HB 1275 also created the Interagency System of Care Council (ISCC) consisting of a member of each state agency representing the ICCCY team, a family member representing a family education and support organization, two special education organization representatives, and a family member appointed by Mississippi Families as Allies (MSFAA).  ISCC serves as the management team for ICCCY with the responsibilities of:

• Collecting and analyzing data and funding strategies, with recommendations made to ICCCY and the Legislature concerning such strategies,
• Coordinating local Multidisciplinary Assessment and Planning (MAP) Teams,
• Applying for grants from public and private sources necessary to carry out its responsibilities.

The MAP Teams that were established in this statute consist of members representing local education, human services, health, mental health, and rehabilitative services, and three additional members, one of whom can represent a family education/support organization with statewide recognition.  While not required, the mental health representative from the local Community Mental Health Center often serves as the MAP Team Leader. TheMAP Teams serve several functions with the primary purpose of diverting children and youth from inappropriate institutional placement:

• Review cases concerning children and youth up to 21 years of age who have a serious emotional disorder (SED) or serious mental illness;
• Develop a service plan that may include existing services and informal supports/services; and
• Monitor and track implementation of the plan and status of the child.

Assessment of Current System

The Center for Mississippi Health Policy contracted with an independent consultant to conduct an assessment of the state’s current System of Care. The consultant gathered relevant information and stakeholder input through site visits to Mississippi as well as reports and documents obtained through the Mississippi Department of Mental Health, Mississippi Families as Allies (MSFAA), Interagency Coordinating Council for Children and Youth (ICCCY) members, and the full Interagency System of Care Council (ISCC).  The following summarizes the key findings and recommendations from the full report.

Key Findings

Many Mississippi children and youth are suffering from serious emotional disorders that are largely treatable.  The best care for such children and youth is provided within the child’s community and family.  Only a small portion of the MS children, youth, and young adults with those disorders is getting access to the most effective care infrastructure – the MAP and “A” Teams. Components to provide appropriate care have been developed and are working effectively in pockets across the state, but broad portions of the state’s population lack access to that care.  The current System of Care infrastructure requires significant support and development to address the unmet behavioral health needs of Mississippi children and their families.

State-level collaboration is being nurtured and developed, primarily by ISCC but with explicit support from ICCCY.  The MAP Teams are effective but reach only a small portion of children and families in need:

• The 1,266 children and families directly served last year (FY08) by 36 MAP Teams are generally receiving the appropriate services they need, and family anecdotal information strongly supports the positive impact of MAP Teams on this small group of Mississippi children and youth.
• The MAP Teams have unquestionably decreased overall system costs for the group of children and youth served, although adequate data to prove that assertion are not available.

Based on the most conservative estimates of the population of need, up to ten times as many children, youth, and families in Mississippi could be appropriately served by the MAP Teams, but the raw capacity to handle that number of children, youth, and families is not currently present.

Figure 3: Location of Map Teams in Mississippi as of November 2009

Mississippi currently faces a unique situation in which three major child-serving systems are striving to address behavioral health needs among the children and youth those systems serve, in addition to the ongoing work of the mental health care system. 

• The education system is implementing, as a result of the Mattie T. Consent Decree, reforms in special education to improve identification and care of students with emotional/behavioral disorders that negatively impact their ability to benefit from education.  Mattie T. includes goals for more accurate identification of special needs among students who are African American, reversing a long-standing trend of disproportionately identifying students in this group as “mentally retarded.”
• The child welfare system is implementing the Olivia Y. Settlement Agreement, which includes, among others, a requirement that children entering state custody receive an assessment to identify potential treatment needs within a short time after entering custody.  If behavioral health or other needs are identified, the agreement describes parameters about addressing them.
• The juvenile justice system is resolving a federal lawsuit through strategies that include substantial changes in behavioral health care for youth committed to the Oakley School, especially in identifying behavioral health needs, assuring access to relevant and effective treatments, and minimizing suicide risks.

Each of these systems would benefit from an expanded System of Care that enables the application of MAP team-like community processes to the populations of need identified within each system.  As a result, the families of Mississippi would benefit through increased ability to successfully raise their own children. 

The broader mental health system that surrounds the MAP teams is doing some good work, with some Community Mental Health Center (CMHC) regions demonstrating significantly more effort and success in working with children and youth than others, but the help offered is not necessarily well-aligned with the needs of those children and youth or with best practices in the field.  Service capacity is a big issue. The only identifiable intensive, community-based service currently supported within the MS system is day treatment. Although important, it is inadequate by itself to create community based care that can defer most placements for treatment reasons.  The partnerships between CMHCs and local school districts that currently support day treatment programming are exemplary of the types of local partnerships that need to be expanded within a System of Care.

On the basis of reported numbers, CMHCs are serving a substantial number of children and adolescents identified as having a serious emotional disturbance (SED).  However, the public system process established to identify children and youth with SED is directly linked to access to services that will be paid for by Medicaid.  Without the label, only more limited services can be accessed.  Therefore, the substantial whole (96%) of children and adolescents reported to be served by the primary mental health system and paid for by Medicaid are identified as SED.  However, the average number and types of services provided to each individual recipient suggest that, in spite of their “serious” emotional disturbance, most children and youth received infrequent and/or short-duration services from the system, which in turn suggests that 1) their needs were not that serious, and/or 2) the system did not respond adequately to their needs.

Medicaid’s MYPAC initiative (Mississippi Youth Programs Around the Clock) is demonstrating that community-based, team-based, and family-driven care can effectively address child, youth, and family needs and simultaneously save tax dollars.  MYPAC is based on identical principles as the System of Care statute and its outcomes point to the possibilities of bringing the System of Care to scale statewide.  The care that children and youth served in MYPAC require is at times more intense than what most community agencies traditionally provide.  The use of more intensive therapeutic options at the community level decreases the number of children who need to go to hospitals or residential treatment agencies, thus saving the costs of unnecessary placements.  More importantly, community-based care allows children and youth in distress to maintain contact with their family and community, important resources in their long-term management of their behavioral disorders.

Recommendations

Recommendation 1:  The current System of Care statute, set to sunset on June 30, 2010, should be reauthorized with minor language changes described in several of the following recommendations.  The statute is already strong, with clear guidance for how a System of Care should function.  The primary hindrance to an effective System of Care in Mississippi is not the language of the statute – it is, instead, the inability to implement what the statute describes at a scale that serves the needs of those children and families who could benefit from the system.

Recommendation 2:  Empower ICCCY by giving it authority to impact policy and funding decisions across all public service sectors touching children and adolescents and adding relevant and necessary voices. This would elevate the importance of state level leadership in improving the alignment and functioning of the major child-and family-serving systems, which could lead to improvements in policy, practice, management, funding, and monitoring of those systems. 

Additional stakeholders should be added to the Council: 

• Other family voices, including additional individuals whose families have been served in public systems;
• A  youth/young adult voice;
• Representatives of private philanthropy, business, and higher education, especially professional training programs relevant to this population;
• A representative of the Attorney General’s Office;
• Representatives of local systems of care;
• Professionals such as psychiatrists, probation officers, special education directors, early childhood experts, to be recommended by the respective professional organizations

The statute could be further strengthened by requiring that any designee of an ICCCY member bring the member’s full decision-making authority in order to serve as a designee.

A simple way to strengthen authority for the empowered ICCCY would be to mandate that any MS child about to be placed in out-of-home care, for reasons other than parental abuse/neglect (the mandate of child protection), or in alternative education environments be served first by the System of Care led by ICCCY, with three goals: 1) preventing restrictive placements if possible, 2) making least restrictive placements when placement is necessary, and 3) reintegrating the child/adolescent back into the community and home (or home-like environment, if necessary) as soon as possible through local monitoring and management. 

Finally, ICCCY should negotiate a meaningful Interagency Agreement that lays out system responsibilities in the many operational areas referenced in these recommendations (e.g., actions to ensure system representation on local MAP teams; funding support for necessary training; system commitment to refer all children and youth at risk for placement to the MAP teams before placements are made). 

Recommendation 3:  Much more organization and support for the local MAP and “A” Teams is needed, as described in the following set of specific recommendations:

Recommendation 3A:  Existing MAP and “A” Teams need support and development.  ICCCY should offer an annual Team Policy Academy to bring together all MAP and “A” Team members from across the state to learn together and plan for the future.

Recommendation 3B: The state system as a whole (with involvement of all interagency partners), and ISCC in particular, must be much more proactive in recruiting family and youth voices to be part of the MAP team process.  The Department of Education’s Office of Parent Outreach should be asked to play an organizing role in this effort.

Recommendation 3C:  The money provided to MAP Teams that collectively funds support for a portion of the MAP team Coordinator position, operational activities, and services/supports to address the needs of families and children should be separated and awarded as three defined funds to accomplish three separate goals:

1. MAP Team Coordinator – Following a model used in other states, Mississippi should provide a specific amount of dollars to support a full-time coordinator, requiring a percentage local match for the position.  The Coordinator’s responsibility could expand to include community education about the MAP team, relationship-building with local partners, community resource development, evaluation data gathering and reporting, and a broader management of interagency partnerships.

• Flexible funds for services/supports – Current practices appear to be relatively clear and require no substantial changes.
• Operational expenses – Pragmatic expenses for the System of Care must be addressed, including transportation, stipends for persons who are not paid to participate, and training in System of Care practices.  This category could also include some level of support for local family and youth support/advocacy groups.

Recommendation 3D:  State agencies must accomplish two important goals:

1. Ensure representation of all key partners on local MAP Teams through state-level requirements that local entities participate fully, with training support to develop the needed skills and knowledge. 

• Establish MAP Teams accessible to families in every Mississippi county. 

Recommendation 4:  ICCCY and ISCC should establish a framework to provide intersystem support, both resources and dedicated recruitment through local agencies, for a statewide advocacy group for youth. Note that this recommendation is linked to Recommendation 3B.  

Recommendation 5:  ICCCY and ISCC should work to develop and implement a “System of Care” training curriculum to be utilized across all public service systems. 

Recommendation 6:  The mental health system must take the lead, employing functional partnerships with other systems, to establish more community-based, intensive care alternatives, using existing partnerships between CMHCs and local schools, required by the Department of Mental Health (DMH), as a template for additional local agreements to create capacity in a broader range of services than currently exists.

Recommendation 7: The DMH must strengthen work in partnership with the University of Mississippi Medicaid Center (UMMC) Department of Psychiatry to develop additional child/adolescent psychiatric capacity.    All options for the expansion of current telemedicine capacities should be explored.

Recommendation 8:  It is recommended that DMH re-examine the purpose of the SED designation and determine the extent to which current processes support that purpose.  Everyone (children, taxpayers, families, workers) would be better served if children and adolescents on a path to a serious emotional disturbance could be identified and served before their difficulties ever reach official SED status.

Recommendation 9A:  The State, across all service agencies, needs to invest in the development and operation of basic management information systems that provide real-time management data, for both planning and day-to-day operational purposes, and align data across information systems.  The System of Care, aimed especially at those children with more challenging and complex needs, requires broader data-driven management style to function most effectively.

Recommendation 9B:  It is highly recommended that DMH develop and utilize a simple, straight-forward quality management system that links the outcomes and experience of children and their families to the provision of service.

Recommendation 10:  ICCCY, with assistance from ISCC, should study the data that suggest that the public service systems respond differentially and somewhat disproportionately to children and adolescents who are African American to determine causes and recommend changes.

Summary

Mississippi initiated a formal statutory System of Care in 1993 and has steadily developed the system so that it has proven itself as a cost effective strategy to address the needs of children and youth with serious emotional and behavioral disorders.  Evidence compiled during the Assessment and Study indicates that those children and youth receiving care through the local MAP and A Teams are achieving positive outcomes, but only a small portion of eligible families are being reached by these teams. Large areas of the state remain unserved. The current System of Care infrastructure requires significant support and development to address the unmet behavioral health needs of Mississippi children and their families and to reduce the unnecessary expenditures that result when care is delayed.

The System of Care can be strengthened by reauthorizing the statutes with certain minor changes and making additional administrative enhancements:

• Expand and empower the Interagency Coordinating Council for Children and Youth by adding additional professional and stakeholder members;
• Strengthen organization and support of MAP and A Teams by establishing a formal policy academy for MAP Team members, recruiting more family and youth members, restructuring funding, ensuring full participation from agency members, implementing a System of Care training curriculum to be used across all public service systems, and systematically expanding the number of teams to reach all Mississippi counties;
• Establish more community-based, intensive care alternatives, using existing partnerships between CMHCs and local schools, and work with UMMC to expand access to psychiatric care; and
• Develop data collection and management information systems that will allow agencies to measure process, quality, and outcomes across agency lines and to monitor the performance of the System of Care.

Sources

1. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA). Systems of Care. Retrieved October 1, 2009, from http://systemsofcare.samhsa.gov.
2. Stroul, B. (1996). Children’s mental health: Creating systems of care in a changing society. Baltimore, MD: Paul H. Brookes Publishing.
3. Kelly, B. (2004). Mississippi system of care diagram. In Schweitzer, T. and McKinnon-Hicks, L. (Eds), The system of care for Mississippi’s children with serious emotional disorders and their families: Implementation overview. Jackson, MS: Division of Children and Youth Services, Mississippi Department of Mental Health. Adapted from Stroul, B. & Friedman, R. (1986). A system of care for children and youth with severe emotional disturbances (rev. ed., p. 30). Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center for Children’s Mental Health.