Timely help for troubled youth: the HomeCare Program integrates services, reduces recidivism rate.
Subject: Juvenile offenders (Care and treatment)
Drugs and youth (Care and treatment)
Psychiatric services (Management)
Home care services (Management)
Home care services industry (Management)
Recidivism (Forecasts and trends)
Recidivism (Control)
Authors: Pearson, Geraldine S.
Hawke, Josephine M.
Dundon, Edith
Muller, Beth
Pub Date: 03/01/2010
Publication: Name: Behavioral Healthcare Publisher: Vendome Group LLC Audience: Academic; Trade Format: Magazine/Journal Subject: Health; Health care industry; Psychology and mental health Copyright: COPYRIGHT 2010 Vendome Group LLC ISSN: 1931-7093
Issue: Date: March, 2010 Source Volume: 30 Source Issue: 3
Topic: Event Code: 200 Management dynamics; 010 Forecasts, trends, outlooks Computer Subject: Company business management; Market trend/market analysis
Product: Product Code: 8098000 Medical Management Services; 8000186 Mental Health Care; 9105250 Mental Health Programs; 8096000 Home Health Care NAICS Code: 56111 Office Administrative Services; 62142 Outpatient Mental Health and Substance Abuse Centers; 92312 Administration of Public Health Programs; 62161 Home Health Care Services
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 223731738
Full Text: Most of the youth involved in the juvenile justice system meet the criteria for a mental health disorder, substance use disorder, or both (1). However, the juvenile justice system traditionally has not provided mental health interventions and mental health providers are not always equipped to deal with the juvenile justice population. Similarly, Bonham noted that the line between adolescent behaviors associated with mental illness and delinquent behaviors may be blurred (2).

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The HomeCare Program was developed in 2003, following a federal consent decree mandating improved mental health services for juvenile justice youth being discharged from detention centers throughout Connecticut (3) At that time, the state of Connecticut awarded funding to the University of Connecticut School of Medicine to establish child/adolescent psychiatric clinics in federally qualified health centers (FQHCs) to address the need for psychiatric prescribers.

The original intent of the HomeCare Program was to provide continuity of care for youth needing medication while in detention and timely access to follow-up care after release. Previously, detention psychiatrists were reluctant to start or change prescription medications for youth in detention because they feared the youth would lose access to timely care upon release. With waits for community child psychiatry appointments ranging from weeks to months, even for those children who entered detention with an existing prescriber, this concern often resulted in a lack of medication treatment during detention or extended detention periods for youth awaiting release into services.

Today, the HomeCare Program provides a psychiatric bridging service that seamlessly transitions youth from juvenile detention to a psychiatric provider in their home community who can coordinate care that meets individual and family needs. To do this effectively, the HomeCare Program uses a collaborative approach, bringing the best models of academic and community care to this complex population. By providing ready access to community psychiatry providers, the program helps youth avoid extended stays in detention. At the same time, it prevents a relapse of psychiatric symptoms due to abrupt discontinuation of psychotropic medication started during detention. This intervention is especially valuable in the initial days after release when youth are at increased risk of re-offending. Based in both FQHCs and mental health clinics throughout Connecticut, the HomeCare Program reflects a developed and implemented model of referral, treatment, and community collaboration within the juvenile justice system.

Care within the community

All referrals to the HomeCare Program must come from juvenile probation, juvenile parole, or adult probation officers. When a referral is made, the HomeCare Program obtains information on current and past medications, prior treatment episodes, reasons for court involvement, and collateral psychiatric evaluations or information. This information, along with direct input from the child's probation officer, allows for a needs-based triage process. Priority is given to individuals who have been detained or incarcerated or those completing a court-ordered inpatient psychiatric evaluation. Each clinic is set up to minimize the time between referral and initial appointment. Traditionally, this time has averaged between six and eight weeks, but averages just 17 days through the HomeCare Program. Using the licensed advanced practice registered nurse (APN)/child psychiatrist collaborative model of care, the intake and psychiatric evaluation are conducted simultaneously to minimize any wait for prescription renewals. If needed, referred HomeCare patients can receive a renewal of their psychotropic medication on the first day of their evaluation. Every effort is made to ensure continuity of care so patients are never without medication.

The HomeCare Program is integrated within the juvenile justice system. This involves interactions/liaisons at many levels: probation officers who make the referrals, Department of Children and Families workers involved with dually committed adolescents, attorneys, detention staff, and judges. Partnership with the probation/parole officer is an invaluable part of the evaluation, treatment, and management of services to each individual. In a psychosocially complex population that tends to resist mental health services, this partnership can provide the support needed to help youth and their families follow through with a psychiatric evaluation. This evaluation becomes part of a collaborative treatment plan that is "owned" by the family, which often results in increased program adherence. In turn, the HomeCare Program staff consults with probation officers, offering support for decisions regarding mental health services for each individual in their HomeCare caseload.

Care within the clinic

The HomeCare program is focused on short-term medication management and psychiatric case management, rather than traditional psychiatric treatment models that rely heavily on individual, family, and group psychotherapy. Most youth involved in the HomeCare Program receive some type of community service or psychotherapy service, including multisystemic therapy, mentoring, or other in-home interventions. What they do not have is a provider who can manage the psychiatric medication that optimizes their ability to "make use" of therapy services. The HomeCare program is focused on meeting an immediate need for medication management to ensure that there is no interruption in this level of care. The HomeCare Program also focuses on strengths-based and culturally sensitive case management and medication management. This involves understanding the particular needs of the adolescent and family referred for care and then working to meet those needs in a non-punitive manner.

In each FQHC/HomeCare clinic location, APNs collaborate with child psychiatrists to provide psychiatric evaluation, short-term psychotropic medication management, and supportive case management services. Physicians and APNs clinically manage their caseloads; physicians provide consultation for the more complex patients while nurses do the case management for both caseloads. Case management includes involvement in school-based meetings, court-based planning meetings, and diagnostic consultations with court personnel. APNs also manage the schedule of the clinic with the FQHC staff. The HomeCare Program staff integrates into the FQHC clinics and enhances child psychiatric services delivered within that system. For every hour of direct clinical service provided to a HomeCare patient, there is at least one hour of indirect care management that is built into the APN workload.

Funding and staffing

Although they are essential to the quality of care provided by the HomeCare Program, many activities that the HomeCare Program staff undertakes (phone contacts, consultations with probation and school staff, attendance at school planning or System of Care meetings) are not directly reimburs able through Medicaid or other third-party sources. Instead, these activities are grant funded, which enables the standard of care to be determined by patient needs rather than reliance on third-party reimbursement.

The bridging function that makes programs like this so successful also is not usually funded in most mental-health and juvenile-justice support programs. However, the HomeCare Program has been able to utilize certain resources that make this function affordable. University, FQHC, and state agency support is critical to the successful functioning of the program. State funding is currently renewed yearly at the original rate of $404,000. There have been no increases in funding but also no reductions. Grant funding is used to support the non-billable case management function of APNs. An hourly rate is charged to the FQHC for the practicing APN and child psychiatrist. This rate has increased once in five years.

Another key to ensuring the quality of care is the program's staff, which consists of APNs and psychiatrists. The HomeCare Program fosters quality by offering unpaid clinical placements to nurses completing master's degrees in psychiatric nursing as well as scheduled rotations to university-paid physician child psychiatry fellows who learn how to deal with psychosocials complex families in the FQHC system. These placements ensure proper staffing for the program while offering a long-term staffing resource when these individuals finish training.

The bridging concept of the program means that APN staff continually work with probation/parole officers to arrange a long-term provider to offer medication management and other psychiatric services. Nurses are willing to do complex case management and to engage with difficult, psychosocially intricate patients and families. They are given program time to accomplish this time-intensive task.

While juvenile justice referrals always take precedence, referrals from the FQHC are also evaluated and treated. This offers staff a mixed caseload, offers the FQHC access to enhanced child psychiatry services, and provides a referral resource for youth in the juvenile justice system.

Multi-level communication and consultation is essential at all levels of the program, involving probation and welfare departments, clients and families, various agencies, and primary-care medical providers. All direct and telephone contacts with clients or others are documented in the HomeCare Program chart. The goal of "no child falling through the cracks of the system" guides the practice.

Why HomeCare works

Since the inception of the HomeCare Program, nearly 1,000 juvenile justice-involved youth have been referred for services. In 2008,73 percent of referrals had been seen for intake. Reasons for not receiving an intake included refusing treatment, re-incarceration, and receiving services elsewhere. Nearly all referrals are accepted for care at the time of referral. About one percent of total referrals have been refused due to high clinical acuity (i.e., needing intensive outpatient programs, partial hospital programs, or hospitalization) or IV drug abuse. The rate for re-referral to the HomeCare Program after discharge averages 15 percent.

While this model does not incorporate specific individual and family treatment, its use of intensive case management, along with medication management, psycho-education, and careful transition to the next level of care has proven to be successful. The program also effectively display show various agencies can work together to simultaneously promote primary and mental health wellness. The dialogue that is established and maintained between the juvenile justice system, the FQHC and program staff, and the youth and his or her family is fundamental in breaking down the barriers that prevent effective treatment. In addition, the program's primary-care setting allows for a focus on general health management of the population including issues involving sleep, obesity, or other general health needs. The FQHC system offers an array of primary-care treatment options that are open to HomeCare Program youth if they don't have a pediatrician or family care provider.

Goals for the future involve integrating a clinical measure of acuity and progress in treatment (such as the Clinical Global Improvement Scale), refining the database, and expanding the staff and clinic sites. These data are essential to better assess the impact that improved continuity of psychiatric care can have on the outcomes of justice-involved youth. Eventually, the HomeCare Program hopes to extend its services to all of Connecticut. Due the particularly high need, at this time, clinics are located in mostly urban communities.

Geraldine S. Pearson, PhD, PMH-CNS, APRN, is an assistant professor at the University of Connecticut School of Medicine, Department of Psychiatry, Child Division. She is also the editor of Perspectives in Psychiatric Care and the director of the HomeCare Program. Josephine M. Hawke, PhD, is an assistant professor of psychiatry at the University of Connecticut School of Medicine. Beth Muller, PMH-CNS, APRN, is a nurse clinician at the HomeCare Program and has worked as a child and adolescent psychiatric clinician since 1987. Edith Dundon, MS, RN, CPNP, is an assistant clinical professor and the undergraduate pediatric coordinator at the University of Massachusetts School of Nursing. For more information, e-mail Dr. Pearson at gpearson@uchc.edu.

BY GERALDINE S. PEARSON, PHD, PMH-CNS, APRN; JOSEPHINE M. HAWKE, PHD; EDITH DUNDON, MS, RN, CPNP; AND BETH MULLER, PMH-CNS, APRN

RELATED ARTICLE: The HomeCare Program in action

Jose, a 14-year-old Hispanic male, is Hearing discharge from a juvenile detention center. Arrested multiple times with several incarcerations, he and his mother agree with the detention child psychiatrist to re-start his stimulant medication (beginning dose of Vyvanse 20 mg, qd). Reports indicate that his behavior is improved when his ADHD (combined type) is treated with medication. He has intermittently taken stimulants throughout latency and early adolescence but frequently missed medication appointments and would stop the medication. Additionally, the child psychiatrist in detention questions whether or not he has a mood disorder and would like this evaluated upon discharge to the community.

His probation officer (PO) has arranged for a community mentor, an after-school program, and therapeutic in-home family support, anticipating his discharge home within two weeks, pending a court hearing. He also refers Jose to the HomeCare Program for further psychiatric evaluation and short term medication management services until a longer term psychiatric provider is secured. The PO faxes the one-page referral form to the HomeCare Program office, where the case is triaged within 48 hours by clinical staff. This triage involves calling the PO to discuss the youngster's psychiatric needs, current medication, and history, When the youth is accepted, the family is directly contacted by the assigned advanced practice nurse (APN) who will schedule a psychiatric evaluation and medication management bridging services. The youngster remains on the stimulant medication needed to treat his ADHD and the family receives care in their home community in the primary care clinic where they receive their general health services. After completion of probation and successful discharge from the in-home services program, his medication management is eventually transferred to his primary care provider in this same clinic.

HomeCare patients' most prominent diagnoses

Complex ADHD

Mood disorder

Depression

Anxiety

References

(1.) Teplin, L. A., Abram, K. Am. McClelland, G. M., Dulcan, M. K., & Mericle, A. A. (2002). Psychiatric disorders in youth in juvenile detention. Archives, of General Psychiatry, 59, 1133-1143.

(2.) Bonham.E. (2006). Adolescent mental health and the juvenile justice system. Pediatric Nursing, 32, 591-595.

(3.) Kosanovich, A., & Joseph, R.M. (2005). Child Welfare Consent Decrees: Analysis of Thirty-Five Court Actions from 1995-2005. Child Welfare League of America, http://www.cwla.org/advocacy/consentdecrees.pdf.
HomeCare patient demographics

Male                        61%

Female                      39%

African American            24%

Bi-racial                    5%

Caucasian                   24%

Hispanic                    47%

Other                      < 1%
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