acute mental health care services for children in pinellas county (florida) annette christy, ph.d....

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

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


43% (n = 15) had past or current justice system involvement

Record Reviews



46% (n = 16) had past or current substance abuse documented

Record Reviews




Insurance Status•51% Private Insurance•26% Medicaid as Primary (6% as Secondary)

Record Reviews




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



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





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



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





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%



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%



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%

7 Key Findings

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/

http://bakeract.fmhi.usf.edu/

acute mental health care services for children in pinellas county (florida) annette christy, ph.d....

Documents

baker act examinations

baker act data processing

baker act examination

data pinellas county

mental health needs

childrens mental health

mental health problems

mental illness