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University of Bath Institute for Policy Research International Partners Symposium: Lost youth in the 21st Century 17-18 September 2014 50% of Americans (including youth) experience a diagnosable mental health disorder over lifetime Initial onset in childhood or adolescence 1 in 4-5 children experiences serious behavioral health disorder Suicide is 3rd leading cause of death in youth ages 10-14; 2nd leading cause of death in youth 15-24 Only 1/3 receive specialized mental health services (Sources: AACAP, 2009; CDC, 2011; Kessler et al., 2005; Merikangas et al., 2010, 2011) Greater disparities in care for people of color Less access to care and fewer services available Less likely to receive needed mental health services More likely to receive poorer quality of care More often misdiagnosed Underrepresented in mental health research (e.g., intervention studies) Less likely to have health insurance (Sources: Fox et al., 2007; Merikangas et al., 2011; President’s New Freedom Commission Report, 2003; USDHHS, 1999) Among adolescents, greatest disparities for youth of color and youth living in poverty Over 42 million adolescents (ages 10-19) in the U.S. (14% of American population) 9.8% lack health insurance Racial & ethnic minorities = 39% of U.S. adolescent population Hispanic and Black children and youth have least access to and use of mental health care Health outcomes disparities for racially and ethnically diverse youth and youth living in poverty (obesity, teen pregnancy, tooth decay, educational achievement) (Sources: Behrens et al., 2013; Fox et al., 2007; U.S. Public Health Service, 2000) In 2011, suicide attempts for Hispanic girls, grades 9-12, were 70% higher than for White girls (http://minorityhealth.hhs.gov/templates/content.aspx ?lvl=3&lvlID=9&ID=6477) In 2012, Major Depressive Episode rate was highest among Latino youth, who were also less likely to received treatment than White youth (http://www.samhsa.gov/data/StatesInBrief/2K14/Nati onal_BHBarometer.pdf) Children & youth in poverty have highest rates of unmet need and highest prevalence rates (Sources: Behrens et al., 2013; Fox et al., 2007; U.S. Public Health Service, 2000) Disparities in the use of mental health services, including outpatient care and psychotropic drug prescriptions, persist for black and Latino children, reports a new study in Health Services Research. “Children’s mental illness is very predictive of poor outcomes later in life— socially, educationally, income-wise and employment-wise.” said lead author Benjamin Lê Cook, Ph.D., senior scientist at the Center for Multicultural mental Health Research at the Cambridge Health Alliance and assistant professor at Harvard Medical School…” (Source: http://www.cfah.org/hbns/2012/mental-health-care-disparities-persist-for-black-and-latino-children) Stigma Negative cultural views on mental illness Self-care decision-making (medications, managing symptoms, appointment follow through) Insurance coverage Workforce shortage Lack of culturally relevant care Inaccuracies in identifying and diagnosing mental health disorders Issues with provider-patient communication Culturally inappropriate patient care plans Ill-prepared clinicians (Sources: President’s New Freedom Commission Report, 2003; Conner et al., 2010; Vega et al., 2009) Challenges Inadequate funding Sustained focus on services for children and youth with serious emotional disturbance Complexity of child mental health service delivery systems and funding Locally-controlled school policies and priorities complicate statefunded school-based efforts Insufficient availability of mental health services, esp. for lowincome children and youth Supports Expanding insurance coverage increases access to services Increasing advocacy across multiple levels effects policy change Promising practices to improve access: Telemedicine/Telepsychiatry, Teacher accreditation and mental health training, Classroom-based socialemotional learning and positive behavioral instructional supports Support and Challenge Varying impact of court actions on access to services Comprehensive school-based care approach increases access to prevention, early intervention and treatment services Multiple child serving systems Fragmented public service systems Silo financing structures, service regulations, electronic records systems Inadequate funding of mental health services Funding and services depend on state of residence and sources of funding available to child and family Funding targets high need children with payment tied to specific diagnoses “When it comes to providing preventive care, early intervention, or multidisciplinary approaches, there are few structural incentives, and many disincentives, to addressing mental wellness.” (Murphey et al., 2014, p. 8.) Insurance funding lags in covering evidence-based practices (Sources: Garland, et al., 2001; Stagman & Cooper, 2010; Stagman & Cooper, 2010; Cooper, 2008) Reduced educational achievement Increased involvement in or relinquishment to child serving systems Substance abuse System cycling Poor employment Adulthood poverty Self-destructive behaviors Exacerbation of mental illness Premature death (Sources: AACAP, 2009; Bullock, 2005; Kapphahn et al., 2006; Stagman & Cooper, 2010; United States General Accounting Office, 2003; Colton & Manderscheid, 2006) Systems of Care for Children’s Mental Health Mental Health Parity and Addiction Equity Act of 2008 and the Children’s Health Insurance Program Reauthorization Act of 2009 Finances collaboration among Increased levels of mental health agencies, families and youth to provide culturally relevant, youth guided and family-driven services using a wraparound service delivery approach Several years of funding to create integrated system structures across child serving systems Overall positive outcomes Concern: Sustainability (Sources: Bailey & Davis, 2012; Murphey et al., 2014) care covered Removed limitations and restrictions on mental health coverage Concern: Managed mental healthcare limitations for chronic illness Patient Protection and Affordable Care Act (ACA) of 2010 Anticipated health care for over 90% of Americans Embeds provisions of Parity Law Emphasizes prevention (with no patient cost sharing), quality of care, efficiencies in healthcare delivery esp. for high-cost chronic diseases (including mental illness) Guaranteed renewal of insurance policy Non-discriminatory premiums (poor health ≠ higher premiums) Supports new healthcare service delivery approaches to increase access and care coordination (esp. integrated health and behavioral healthcare) Recognizes importance of social determinants of health Significant role of primary care providers Emerging evidence base is favorable for patient and fiscal outcomes Concerns: Focus on adult healthcare models and ability to meet demand for providers (Sources: Bazelon Center for Mental Health Law, 2010; Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE), 2013) Young adults (up to age 26) may remain on parents’ health insurance Current and former children in foster care Medicaid eligible until age 26 Special catastrophic health plan for young adults under age 30 ACA expected to make 4.2 million more adolescent U.S. citizens and legal immigrants eligible for healthcare - 35% Latino, 16% non-Latino African American; 19% rural) Youth healthcare needs differ from adults - Fewer chronic conditions (17-20%) - Need access to healthcare, preventive and wellness care, health education (Sources: Bazelon Center for Mental Health Law, 2010; Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE), 2013) Covered child and adolescent preventive services and screenings: • Behavioral assessments for adolescents • counseling, sexually transmitted infection prevention counseling, contraception and patient education screening for sexually active adolescents, immunizations, obesity screening, drugs Essential benefits relevant to adolescents: • Pediatric dental and vision services for children up to age 19 • Habilitative services for developmental disorders • Mental health and substance use disorder services, including behavioral health treatment (Sources: Bazelon Center for Mental Health Law, 2010; Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE), 2013) Other relevant ACA provisions • School-based health centers (capital funds) • Teen pregnancy prevention programs • Home visiting programs – support for families to improve health and development outcomes for at-risk children • Childhood obesity demonstration project (ages 2-12) • Expansion of community health centers – access to a “usual source of care” Concern: Needs of youth will get inadequate attention if innovations in integrating care do not keep pace with adultfocused initiatives (Sources: Bazelon Center for Mental Health Law, 2010; Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE), 2013) Health conditions Developmental conditions Asthma Learning disabilities Allergies Speech problems Obesity Autism spectrum disorders Behavioral health conditions Attention deficit/attention deficit hyperactivity disorder (ADD/ADHD) Oppositional defiant or conduct disorder Anxiety Depression Substance use (Sources: Bloom, et al., 2011; CDC, http://www.cdc.gov/chronicdisease/overview/; Kolko & Perrin, 2014; U.S. Department of Health & Human Services, 2011) Families generally seek help most often from family doctor In rural communities, families seek help from: Physician (62.5%), teachers (55.1%), family/friends (54.7%), counselor/therapist (24.7%), pastor (10.7%), other (2.8%) Only 21% were in clinically significant range Over 90% of children in U.S. visit a primary care provider annually Behavior problems are among top pediatric primary care physician concerns Primary care clinicians (PCC) prescribe most psychotropic medications in the U.S. Low rates of problem identification remain among PCCs PCCs receive little training in recognizing and treating mental health issues PCCs report payment barriers and problems accessing mental health specialists (Sources: Arndofer et al., 1999; Polaha et al., 2010, Campo et al., 2005) Residential and inpatient care with communitybased care Children’s mental health into K-12 schools (Source: Behrens et al., 2013) Trends over past 20 years: Integrate… Primary medical and mental health care Family priorities (family voice) into plans of care Integrated care • Improves health outcomes for adults • Is cost effective for adults (Sources: Collins et al., 2010; Milliman, Inc. et al., 2014) Emerging child and adolescent adapted integrated models showing promise • Standardized screening and assessment tools • Evidence informed practices • Medication and management • Team approach • Care management • Quality control • Behavioral health consultant Little evidence exists to support integrated care efforts for adolescents in the U.S. Consensus recommendations to improve adolescent healthcare: Increase adolescent and parent engagement and self-care management Improve clinical preventive services to reduce risk Integrate physical, behavioral and reproductive health services Use combination of Four Quadrant Clinical Integration Model along with Chronic Care and Systems of Care Models to design integrated care practice Focus on multiple levels of study: (1) child/youth; (2) caregiver/family; (3) organizational relationships, (4) cost-effectiveness Programs of practice: Bright Futures; school-based integrated care (Sources: SAMHSA-HRSA Center for Integrated Health Solutions, 2013; Campo, 2005; Foy et al., 2010) Access to care with shifts created by the ACA Use of digital technology for psychosocial screening and assessment Decision support technologies for team planning and management Access to medication protocols for primary care providers Health systems transformation Process evaluation of provider practices relevant to integrated care Comparative effectiveness research (Source: Kolko et al., 2012)