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Connell, Ph.D. Hillary Heinze, M.A. Yale University School of Medicine Division of Prevention and Community Research The Consultation Center,0" dP3i%qxOverview of PresentationReview CIS performance prior to Standards Describe clients served by CIS Demographic & clinical characteristics Patterns of service delivery Discharge outcomes Length of stay in program Discuss findings & program implicationsBI <r <( <I r ( LFChildren s Intensive Services (CIS)Intensive community & home-based mental and behavioral health program for children with SED Intended to provide a  continuum of care for medically necessary services Designed to address needs of the child within his/her environmental context`OInitial Evaluation of CISPurpose  Provide statewide and agency-level information on: Demographic/clinical characteristics of clients Service utilization patterns Methods: Annual administrative data pull Provider time study Sample: Nearly 3,000 children served in FY03x>N 5- 4N 5 - PDemographic CharacteristicsAge % 0-2 0 3-5 10 6-11 37 12-17 51 18+ 2 Gender % Males 59 Females 40`@ ! !  Race/Ethnicity % African American 11 American Indian 2 Asian/Pac. Island 1 Caucasian 69 Hispanic 16 Other 9 Missing 6 Note: Participants may have indicated more than one race>:9QClinical CharacteristicsDiagnosis % Adjustment 23 Anxiety 13 Behavior 57 Develop/LD 7 Mood 32 Psychosis 1 Personality 1 Substance Use 3 Missing 10 Note: Participants may have more than one diagnosis 7 Y4   Functioning-CGAS % 10-30 2 31-40 11 41-50 35 51-60 40 61-100 11 Missing 11 Note: Lower scores indicate poorer functioning >11+btService Hrs/Wk by Clinical Indicator July 2002  June 2003&;%")" S Average Service Mix for ChildrenTU&Length of Stay in CIS (Months Active)''(V"Implications of Initial EvaluationUChildren in CIS receive more service time than traditional outpatient therapy clients Children are receiving a mix of service modalities Services are being delivered by a mix of service providers However: Service delivery was less than anticipated for some clients Child clinical characteristics not associated with service delivery patterns&2c(CIS  Levels of Care aLevel 1: Crisis Intervention M-CGAS: 10-30 6-14 hrs of direct clinical service/week Level 2: Standard Care M-CGAS: 31-40 2-10 hrs of direct clinical service/week Level 3: Intermediate Care M-CGAS: 41-50 2-5 hrs of direct clinical service/week Level 4: Maintenance Care M-CGAS: 51-60 .5-1 hr of direct clinical service/week 2 hrs case management/monthZ7ZZ7ZZ6ZZSZ776    S3djCurrent Evaluation Phase  Implementation PerformanceMethodology: Monthly MIS data extraction New admissions demographic/clinical data Monthly client updates Service data Discharge data2 `x`  xzCurrent CIS Evaluation April 2004  March 2005 Demographic and Clinical InformationUUvDCIS Admission & Discharge Pattern Total Population Served (N = 2606)"E""&#" {Demographic Information}4Age at Admission Total Population Served (N = 2606) 05 ""$ ~)Gender Total Population Served (N = 2606)*#"1Race/Ethnicity Total Population Served (N = 2606)2# s~ Clinical Information9f9CIS Level at Admission Total Population Served (N = 2606):#   =gOhio Scales Admission ScoresJiAdmission CAFAS Sample78% of cases (2038 children) eligible for admission CAFAS (including those in care prior to Standards) Enrolled 30 days or more Age 6 or older CAFAS data was available for 58% of eligible cases (1195 children)Vh*De*$KjLkMlCAFAS Scores by Admission Group & JService Utilization Data What did Children in CIS Receive for Treatment?KKWhat Happens in CIS in a Week? wService Utilization Review examined several issues related to typical service week in CIS: Average amount of service / week (Hours) Break-down of service mix Break-down of service provider credentials Data are analyzed by calendar week and then aggregated to a monthly average (after weighting for # active clients / week). Analyses are run at the provider and State level.<[ZoZZ[op}Service Hrs/Wk by CIS Level April  December 2004 (1st 6 months)DA")" *  " "Service Hrs/Wk by CIS Level January  March 2005 (Most Recent Quarter)&G")+" %Average Service Mix for Children January  March 2005 (Most Recent Quarter)"L!&+"  'Weekly Service Hours by Provider Type January  March 2005 (Most Recent Quarter) .R&$*" $ (Service Location (% of Time) January  March 2005 (Most Recent Quarter)"I&+"  *VService Utilization Data How is CIS Treatment being delivered to individual children?WWZ!Child 1: White male, 8 years old ""\"Child 2: White male, 12 years old ^&Child 3: Hispanic female, 14 years oldNm*Discharge Data Who exited CIS this year?&+On;Demographic Characteristics Discharge Population (N = 1517)$< Age % 0-2 1 3-5 10 6-11 34 12-17 53 18+ 2 Gender % Males 57 Females 42`@ ! ! Race/Ethnicity % African American 9 American Indian 2 Asian/Pac. Island 1 Caucasian 53 Hispanic 19 Other 5 Multiracial 5 Missing 6 2Po9Clinical Characteristics Discharge Population (N = 1517) &: $Diagnosis (admission) % Adjustment 20 Anxiety 21 Behavior 63 Develop/LD 11 Relationship 13 Mood 34 Psychosis 1 Personality 1 Substance Use 2 Missing 2 Note: Participants may have more than one diagnosis ZZ7ZZ  Y4   Functioning-CGAS % 10-30 1 31-40 12 41-50 47 51-60 24 61-100 6 Missing 9 Note: Lower scores indicate poorer functioning >11Qp7CIS Level at Discharge Discharge Population (N = 1517)8  Rq9Reason for Discharge (%) Discharge Population (N = 1517):  Sr8Discharge Placement (%) Discharge Population (N = 1517)9  XwAdmission to Discharge Changesizj{k|$Who is missing a CAFAS at Discharge?%%&CAFAS Present (N=513) Age: M=12.3 Race 58% White 39% Minority Residence 72% Private 10% Public Housing 8% Unknown Primary Payment Medicaid 44% Rite Care 49% Greater clinical impairment CIS Level Axis I&II. 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H H 0޽h ? 33fZfy___PPT10Y+D=' = @B +-'-K0 py(    6 QQ g)Referral Source New Admissions (N = 2606)"** l  0A E ??P  E H  0޽h ? 33fZfy___PPT10Y+D=' = @B + -'-K0  `(  `x ` c $80    H ` 0޽h ? 33fZfy___PPT10Y+D=' = @B + -'-K0 `{(  x  c $8@`   l  0A  ??VpP  X  07     PMean M-CGAS Scores Overall: 44 Crisis: 31 Standard: 38 Intermed.: 44 Maint.: 514>>,8 uMH  0޽h ? 33fZfy___PPT10Y+D=' = @B +-K'-K0  d(  d d 6DgQQ FClinical Diagnoses by Disorder Type Total Population Served (N = 2606).G#*(# l d 0A * ??P  * H d 0޽h ? 33fZfy___PPT10Y+D=' = @B +-L'-K0 cl(  l l 6KQQ ENumber of Diagnosed Disorder Types Total Population Served (N = 2606)"F#*# l l 0A . ??! . H l 0޽h ? f33fZfy___PPT10Y+D=' = @B +-M'-K0 t(  t t 6QpQ u7Axis IV Psychosocial Problems New Admissions (N = 2606)"8* l t 0A  ??=  H t 0޽h ? 33fZfy___PPT10Y+D=' = @B +t -'-K0 x(  x  c $$8@`    0 HA L ?8BqJH L $ 0 H  0޽h ? f33fZf___PPT10.S+DD' = @B DS' = @BA?%,( < +O%,( < +DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(+0+(+ 0+ -'-K0 6(    6| 0 ,$ 0 dCAFAS Analyses0*H  0޽h ? f33fZfy___PPT10Y+D=' = @B + -'-K0  0(   x   c $8@`   x   c $8  H   0޽h ? f33fZfy___PPT10Y+D=' = @B +-'-K0 `(    64#Qpd +Admission CAFAS Results (Age > 6; N = 1195)<,*"""l  0A  ??@   H  0޽h ? 33fZfy___PPT10Y+D=' = @B +-'-K0 j(    6 5   |(Identification of Admission CAFAS Groups)0)"l  0A  ??!&  H  0޽h ? f33fZfy___PPT10Y+D=' = @B + -'-K0 @8 (   x   c $.8@`   x   c $(s8 `     0A  ??m+i8  $ 0H   0޽h ? f3v0e>[  ___PPT10 +afADs ' = @B D. ' = @BA?%,( < +O%,( < +DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* %(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* %(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* %(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* %(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* %(+0+(+  0+ -'-K0  (  x  c $ 80    H  0޽h ? 33fZfy___PPT10Y+D=' = @B + -'-K0 ~(  ~  s *8@`     s *`8@P<$ 0  "p`PpH  0޽h ? 3333___PPT10i.(`n+D=' = @B + -'-K0 PJ(   0  `A 8 ? ?8R 8  0  `A : ? ?8RH : $ 0 ~  s *8@`   H  0޽h ? f3v0e>[___PPT10++B#style.visibility<*%(+0+(+ 0+ -'-K0 \ J(   0  `A > ? ?8P >  0  `A < ? ?8PH < $ 0 ~  s **8@`   H  0޽h ? f3v0e>[___PPT10+]%DO' = @B D ' = @BA?%,( < +O%,( < +DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(+0+(+ 0+,1 -['-K0 @8p(  x  c $L38      c $H48 `<$ 0  l  0A N ??oyb N H  0޽h ? f3v0e>[y___PPT10Y+D=' = @B +1 -]'-K0 @8@(  x  c $d=8     c $`>8 `<$ 0  l  0A R ??q R H  0޽h ? f3v0e>[y___PPT10Y+D=' = @B +1 -^'-K0 @8@@ (   x   c $|G8@`      c $xH8 `<$ 0  l   0A P ??q P H   0޽h ? f3v0e>[y___PPT10Y+D=' = @B + -'-K0   ,(  ,x , c $\80    H , 0޽h ? 33fZfy___PPT10Y+D=' = @B +e -'-K0 tl@ x(  xx x c $S8`   l x 0A  ??   @` x# #" & @`  x B\V?@`F>6___PPT9 >* " dHB x C @`HB  x C @`HB  x C @@HB  x C ``H x 0޽h ? f33fZfy___PPT10Y+D=' = @B +e -'-K0 tlP (  x  c $x^8`   l  0A  ??   @` # #" & @`   B`?@`F>6___PPT9 >* " dHB  C @`HB  C @`HB  C @@HB   C ``H  0޽h ? f33fZfy___PPT10Y+D=' = @B +e -'-K0 tl (  x  c $$d8   l  0A  ??   @` # #" & @`   Bj?@`F>6___PPT9 >* " dHB  C @`HB  C @`HB  C @@HB   C ``H  0޽h ? f33fZfy___PPT10Y+D=' = @B + -'-K0  `((  (x ( c $X80    H ( 0޽h ? 33fZfy___PPT10Y+D=' = @B + -'-K0  p,(  ,x , c $L8   x , c $8@   x , c $8   H , 0޽h ? f33fZfy___PPT10Y+D=' = @B + -'-K0  4(  4x 4 c $88`   x 4 c $8   x 4 c $8 `  H 4 0޽h ? f33fZfy___PPT10Y+D=' = @B + -'-K0 <$(  <x < c $൤8@`   l < 0A&  ??   H < 0޽h ? 33fZfy___PPT10Y+D=' = @B + -'-K0 D$(  Dx D c $8    l D 0A T ?? T H D 0޽h ? 33fZfy___PPT10Y+D=' = @B + -'-K0 L$(  Lx L c $Ƥ8    l L 0A V ?? V H L 0޽h ? 33fZfy___PPT10Y+D=' = @B + -'-K0 pL(  px p c $̤8@`    p0 HA+  ?8CpJ  H p 0޽h ? f33fZf___PPT10i.S+D=' = @B +-'-K0 r+(    6٤ @` jDischarge CAFAS Sample0*  0 @` 44% of cases (919 children) eligible for discharge CAFAS Enrolled at least 90 days before discharge Age 6 or older CAFAS data was available for 56% of eligible cases (513 children):0nZZ:0nKZB0nZZ6:!H  0޽h ? f33fZfy___PPT10Y+D=' = @B +-'-K0 (    6ߤQp CCAFAS at Discharge (N = 919) (Age > 6 yrs; in CIS 90 days or more)<D*$$ $l  0A*  ??@   H  0޽h ? f33fZfy___PPT10Y+D=' = @B + -'-K0 & }(  x  c $T8    ~  s *8@   x  c $8 `  H  0޽h ? f33fZfy___PPT10Y+D=' = @B +#-'-K0 2*t(  t t 6t: @` 8Admission to Discharge Changes CAFAS Total Score (N=424)(90*$ t HA  ? BqJ  H t 0޽h ? f33fZfy___PPT10Y+D=' = @B +!-'-K0 0(`T|(  | | 6dG @` 6Admission to Discharge Changes CAFAS Subscales (N=424)(70*$ | HA-  ? BqJ  H | 0޽h ? f33fZfy___PPT10Y+D=' = @B + -'-K0  `(  x  c $LK80p   H  0޽h ? 33fZfy___PPT10Y+D=' = @B + -'-K0 @0(  x  c $X8@`   x  c $Y8@   H  0޽h ? f33fZfy___PPT10Y+D=' = @B +  -'-K0 x'3(  r 1 <A 1?" @rx  c $_8`   z  @  2  ` ,$D 0B . BD33o?" @ B / BD33o?"@ @ D 3 04e ,$ 0 @Note: LOS decreases to 4.8 months if time in Level 4 is excluded0A= uMH  0޽h ? f33fZf___PPT10+RD' = @B DF' = @BA?%,( < +O%,( < +D4' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*2%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*3%(+8+0+3 + -'-K0 n0(  x  c $v8@`   x  c $dw8   H  0޽h ? 33fZfy___PPT10Y+D=' = @B + 0  <m(  <^ < S @'J    < c $ҟ@ 0(l  TL___PPT9.& Updated 6/30/05 Differences from QI Younger children admitted. Greater percentages of children age 3-11 as compared to QI. QI mean age 11.6 years @%o" %oH < 0޽h ? 33 0 w D(  D^ D S @'J   q D c $\@ 0(`  H@___PPT9" WUpdated 7/12/05 Differences from QI Greater percentage of males than in QI (52% in QI) ,$4" $4H D 0޽h ? 33  0 0LZ(  L^ L S @'J    L c $@ 0(`  H@___PPT9" Updated 7/13/05. Is the following issue ok in the new data set?? Differences from QI Greater percentage of Latino children (as compared to 11% in QI); Slightly Smaller percentages of Caucasian, Multi-racial, Native American, and African American Children. Discussion  recoded Hispanic for Providence if Hispanic+Other checked.<U" H" UH L 0޽h ? 33l  0 ,$@h(  h^ h S @'J    h c $@ 0(l  TL___PPT9.& VUpdated 7/13/05 Differences from Q I Relational Disorder (e.g., reactive attachment, parent-child relationship problem, maltreatment; 14% of children diagnoses).Was not computed in QI Smaller percentage of children diagnosed with mood (29 vs. 36% in QI), anxiety (11 vs. 15% in QI), and adjustment (19 vs. 23%). Maybe less likely to note internalizing difficulties in school. Axis I & II data missing for 7.8% of new admissions (largely east bay (n=8) and family services (n=28)) @+" +H h 0޽h ? 33   0 Pp\(  p^ p S @'J    p c $@ 0(   R>Updated 7/13/05 Not computed in QI 83% have 1 or 2 diagnoses.H p 0޽h ? 33 0 `x((  x^ x S @'J    x c $К@ 0(    H x 0޽h ? 33% 0  ((   ^   S @'J      c $@ 0(    H   0޽h ? 33' 0 )(  ^  S @'J     c $Ǚ@ 0(    Delete (?)H  0޽h ? 33( 0 ZR@}$(  $^ $ S @'J   L $ c $Ou@ 0(   ~Summary of Service Delivery Variation in amount of service and type of service occurs by level  though not dramatically so. Children appear to be receiving a mix of individual, family, group, and case management services. Children are receiving about 40% of services from Bachelors-level providers or lower, and about 60% of services from Masters-level clinicians. Services are being delivered in a broad range of settings  though primarily office and  other locations. Note: Quarter runs July-September  helps explain lack of school-based services during the quarter F <c <bH $ 0޽h ? 33 L 0 0\(  ^  S @'J      c $^u@   ___PPT9tl  Children s Intensive Services (CIS) 1. A community and home-based mental and behavioral health program designed to meet the needs of children with serious emotional and/or behavioral disturbances (SED) designed for children presenting with mental health issues that put them at risk for more restrictive living arrangements, including settings which may be out of the home and/or out of their community (e.g., juvenile justice placements, psychiatric hospitalization, etc.). Intended to provide a  continuum of care for medically necessary services Crisis Stabilization/Assessment/Intervention Medication Evaluation & Management Outpatient Tx (individual/family/group therapy) Therapeutic Case Management Service Coordination Other Therapeutic Supports (Assessment, Recreation, etc.) As the focus is on the child within the roots of his/her social environment, treatment is individualized to provide optimal combination of direct and collateral services and case management activities to address the multiple, complex needs of child and family. Designed to address needs of the child within his/her environmental context Primarily a family focus, but should also include broader context of school/community. Goals of CIS Provide intensive clinical level of services and supports to the child and family Help avoid preventable inpatient psychiatric admissions Support the timely return of children to the community Provide community-based supports to children with acute needs$K" R" W $  K   R W   CH  0޽h ? 33fO 0 &0 (   ^   S @'J   u   c $Xu@ (  u Methods: Statewide Administrative Data Pull Data collected from 2/1/2002 through 6/30/2003 across nine CIS provider agencies MIS data was constructed as an annual file pull  very labor intensive and unclear how well data was tracked historically (i.e., many providers over-write data as new information is collected such as level of functioning, diagnoses, etc.) Admission & Discharge Data: Service Utilization Review examined several issues related to typical service week in CIS: Average amount of service / week (Hours) Break-down of service mix / week Break-down of service provider type / week Data was analyzed by calendar week and then aggregated for quarterly and annual analysis (after weighting for # active clients / week).  v\v C @C c  C  C \C vC C H   0޽h ? 33GP 0 |((  (^ ( S @'J   u ( c $@Tu@ 0(  u )(updated) Approximately 90 percent of children were between the ages of 6 and 18 (at admission), Half the children served were 12-17. Mean = 11.5 More males than females Predominately Caucasian, though ethnicity varied across agency. Time saver: refer to notes, go over in more detail in phase 22 @@H ( 0޽h ? 33Q 0  0O(  0^ 0 S @'J   u 0 c $u@ 0(  u ECMC UPDATE CGAS DATA High rates of behavior and mood disorders Perhaps want to describe the CGAS categories, roughly. Mean C-GAS = 51.9 However, higher levels of functioning than expected (?) Time saver: (same as previous)2H 0 0޽h ? 33S 0 ;@F(  @^ @ S @'J   u @ c $u@ 0(  u <(updated) Mostly case-management and therapy, however, Therapy not broken down by modality (group, family, individual). Respit= 0.4% Time save: delete (or keep in notes), discuss service mix in phase 22 ~EEzMH @ 0޽h ? 33pT 0 0(H(  H^ H S @'J   u" H c $tu@ 0(  u ~(Updated) Do we want to keep this one in? Time save: delete slide altogether, information relatively less important to share +TH H 0޽h ? 33pU 0 0(P(  P^ P S @'J   u" P c $u@ 0(  u ~SKIP IF TIME IS TOO LONG Review slide  then indicate we can also look at this information by provider and note that median LOS ranges from 3-6 months  a 3-month difference across programs!H P 0޽h ? 33B V 0   X (  X^ X S @'J   u  X c $u@ 0(z  ubZ___PPT9<4  ZDevelopment of New CIS Standards All providers had to  re-apply to become certified providers of CIS under a new set of performance standards. Standards were developed by DCYF based upon data collected through this evaluation pertaining to clinical population and service delivery patterns Major changes to program focused on Implementation of  Levels of Care (see next slide): Level 1: Crisis Intervention (M-CGAS 10-30); 6-14 hrs of direct clinical service per week including emergency care, medication evaluation, therapeutic case mgmt, therapeutic intervention Level 2: Standard Care (M-CGAS 31-40); 2-10 hrs of direct clinical service per week including family assessment, home/community/school based Tx, case mgmt Level 3: Intermediate Care (M-CGAS 41-50); 2-5 hrs of direct clinical service per week including above but with 40% by BA or lower Level 4: Maintenance Care (M-CGAS 51-60); .5-1 hr of direct clinical service per week and 2 hrs case mgmt per month. CIS intended as 6-month program but with flexibility as necessary for clinical needs of child.p!^" O`" !LO` dH X 0޽h ? 33E 0 "@t(  tX t C @'J   u t S \u@ 0(  u After adjusting for time at Level 4  median length of stay drops to 4.8 months.H t 0޽h ? 3380___PPT10.)QZ 0 @|((  |^ | S @'J   u | c $X#@ 0(  u MHS  : FY05Q3 Service hours per Week (by Type of Service) 8 year old White Male admitted in January  05. Admission M-CGAS: 44 (Level 3); Dx: Behavior & Anxiety Disorder Disorder. Residence (admit): Private. Still in care  i xTH | 0޽h ? 33\ 0 pP(  ^  S @'J   #  c $#@ 0(  # FNEWP  : FY05Q3 Service hours per Week (by Type of Service) 12 year old White Male admitted in Oct  04. Admission M-CGAS: 31 (Level 2); Dx: Behavior & Anxiety Disorder Disorder. Residence (Admission): Homeless. Still in care 0<+ },3H  0޽h ? 33@^ 0 0(  ^  S @'J   #  c $|#@ 0(  # PROV  : FY05Q3 Service hours per Week (by Type of Service) 14 year old Hispanic Female admitted in Sept  04. Admission M-CGAS: 35 (Level 2); Dx: PTSD (Anxiety Disorder) and Attachment (Relational Disorder). Residence (Private): Homeless. Still in care 8:1 ,oH  0޽h ? 33" 0 jbPl(  X  C @'J   #b  S #@ 0(  # This graph shows the median number of service hours/week for children in CIS and broken out by level of care. NOTE: 50% of children receive at least the median number of hours of service/week for each level. Now  this graph adds in additional information to show the degree of variation around the median # of hours/week  the bars represent the 25th and 75th percentiles of service receipt. Variation in service delivery is wider at Levels 1 and 2 and smaller for levels 3 & 4, indicating that the amount of service children receive on average is more consistent at the lower levels of care. 6V_H  0޽h ? 3380___PPT10.2'b 0 vn(  ^  S @'J   #h  c $<#@ 0(  # This graph shows the median number of service hours/week for children in CIS and broken out by level of care. NOTE: 50% of children receive at least the median number of hours of service/week for each level. Now  this graph adds in additional information to show the degree of variation around the median # of hours/week  the bars represent the 25th and 75th percentiles of service receipt. Variation in service delivery is wider at Levels 1 and 2 and smaller for levels 3 & 4, indicating that the amount of service children receive on average is more consistent at the lower levels of care. 6V_H  0޽h ? 3380___PPT10.2'B c 0   0R (  ^  S @'J   #   c $|#@ 0(z  #bZ___PPT9<4  ZDevelopment of New CIS Standards All providers had to  re-apply to become certified providers of CIS under a new set of performance standards. Standards were developed by DCYF based upon data collected through this evaluation pertaining to clinical population and service delivery patterns Major changes to program focused on Implementation of  Levels of Care (see next slide): Level 1: Crisis Intervention (M-CGAS 10-30); 6-14 hrs of direct clinical service per week including emergency care, medication evaluation, therapeutic case mgmt, therapeutic intervention Level 2: Standard Care (M-CGAS 31-40); 2-10 hrs of direct clinical service per week including family assessment, home/community/school based Tx, case mgmt Level 3: Intermediate Care (M-CGAS 41-50); 2-5 hrs of direct clinical service per week including above but with 40% by BA or lower Level 4: Maintenance Care (M-CGAS 51-60); .5-1 hr of direct clinical service per week and 2 hrs case mgmt per month. CIS intended as 6-month program but with flexibility as necessary for clinical needs of child.p!^" O`" !LO` dH  0޽h ? 33d 0 bZ0(  ^  S @'J   #T  c $@ 0(  # Demographic/Clinical Data (at admission) Age at admission, gender, race, etc. CIS Level & M-CGAS scores Diagnosis, Clinical Instruments (Ohio Scales, CAFAS) CIS changes (among Total Population) Changes in CIS Level and clinical instruments Changes in Residence Individual Treatment Plan (ITP) dates Service Utilization data Type of service provided Length of session Credentials of provider Discharge Information CIS Level & M-CGAS scores Clinical Instruments ( Ohio Scales, CAFAS) Discharge Reason & Placement )t&iCb) t & i  C   b   H  0޽h ? 33f 0 pF(  ^  S @'J   #  c $l#@ 0(  # <(Updated 7/13/05 Consistent with QI data H  0޽h ? 33g 0 *(  X  C @'J     S ȳ@ 0(   ,Overall, 87% fall in clinical range on Problem Scale and 84% fall in clinical range on Functioning Scale By Level: Crisis (87% Problem; 88% Functioning) Standard (94% Problem; 89% Functioning) Intermediate (86% Problem; 84% Functioning) Maintenance (51% Problem; 63% Functioning)H  0޽h ? 3380___PPT10.7_j 0 0(  ^  S @'J     c $@ 0(   o1195 includes all children completing admission cafas age 6 years or older (e.g., regardless of length of stay)0;H  0޽h ? 33Dk 0 0(  ^  S @'J     c $h@ 0(b  JB___PPT9$ 8As CIS provides services to over 2000 children and their families per year, identification of clinical subgroups may facilitate assessment procedures and guide treatment planning, thereby improving treatment effectiveness and overall quality of care Using Latent Class analyses, CAFAS subscale scores grouped statistically to form five distinct subgroups: Mild Problems, Behavior Problems, Community Problems, Substance Abuse, and Self-Harm Internalizing T0nZZZ'H  0޽h ? 33<l 0 P$(  $^ $ S @'J    $ c $@ 0(   This slide depicts how subgroups vary across the eight CAFAS subscales Mild Problems-low across scales Behavior Problems elevated on School, Home, Behavior, and Mood Community elevated on school, home, behavior, mood and community Substance Abuse elevated on School, home, behavior, mood and drug abuse Self-Harm elevated on School, Behavior, Mood and Self-Harm Additionally, subgroups differ by Demographic and Clinical Characteristics On this table, Subgroups listed across the top, demographic and clinical characteristics are listed on the right. Cell therefore indicate distinguishing demographic and clinical characteristics significantly different from other subgroups (From Brief) CAFAS subscale scores appear to be useful in identifying clinical subgroups among children exhibiting severe pathology, thus providing more depth and breath of information than global or uni-dimensional indices of functioning. Distributions of demographic and clinical characteristics across CAFAS subgroups highlight unique strengths, areas of need, and accordingly, potential areas and avenues for clinical focus. Subgroup specificity can guide treatment planning by facilitating identification of interventions empirically supported and demographically sensitive for identified subgroup characteristics .l "  qH $ 0޽h ? 33Gn 0 0(  0^ 0 S @'J    0 c $,@ 0(   )(updated) Approximately 90 percent of children were between the ages of 6 and 18 (at admission), Half the children served were 12-17. Mean = 11.5 More males than females Predominately Caucasian, though ethnicity varied across agency. Time saver: refer to notes, go over in more detail in phase 22 @@H 0 0޽h ? 33o 0 08O(  8^ 8 S @'J    8 c $@ 0(   ECMC UPDATE CGAS DATA High rates of behavior and mood disorders Perhaps want to describe the CGAS categories, roughly. Mean C-GAS = 51.9 However, higher levels of functioning than expected (?) Time saver: (same as previous)2H 8 0޽h ? 33p 0 p@((  @^ @ S @'J    @ c $Ę@ 0(    H @ 0޽h ? 33q 0 H((  H^ H S @'J    H c $P@ 0(    H H 0޽h ? 33r 0 P^(  P^ P S @'J    P c $@ 0(   T@Other encompasses all placements not indicated in the categoriesH P 0޽h ? 33Gx 0 x(  x^ x S @'J    x c $@ 0(   WChildren that have discharge and admission cafas (83% of children with discharge CAFAS)+(H x 0޽h ? 33Gy 0 (  ^  S @'J     c $@ 0(   WChildren that have discharge and admission cafas (83% of children with discharge CAFAS)+(H  0޽h ? 33|{ 0 <4 {(  ^  S @'J   .  c $@ 0(   We see lower levels of impairment across CAFAS subscales; however, high rates of missingness limit our ability to interpret these findings. Q 1H  0޽h ? 33 | 0 P H @ (  ^  S @'J   B   c $8@ 0(   X To better understand children that are missing discharge cafas data, we compared admission demographic and clinical characteristics among  Discharge CAFAS Missing and  Discharge CAFAS Present groups. These analyses only include children eligible for Discharge CAFAS by age and length of stay. Clinical Impairment: Children with a discharge CAFAS were more likely to have been admitted to crisis or standard (14% vs. 11%) and less likely to be admitted to maintenance (5 vs. 10%), however, for children without discharge CAFAS, more admission CIS admission data is also missing (14 vs. 1%) Children with discharge Cafas present were more likely to have the following axis I & II diagnoses at admission: adjustment (~1.5%), anxiety (~2%), relationship (~6%), mood (~6%, and substance abuse (~2%), and they were more than 1 diagnosis (57% vs. 48%) And educational and environmental axis IV problems (~7% & 4%, respectively) Children with Missing CAFAS were more impaired on the following axis IV indices at admission: health care (~3%) and legal problems (~5%). Children with discharge cafas were more impaired on both admission Ohio problem (69 vs. 55%) and functioning scales (67 vs. 53%) (in need of services beyond outpatient care); however, children missing discharge cafas were also more likely to have missing admission ohio scale data (36% vs. 20%. Children with discharge CAFAS were more likely to have had a psychiatric hospitalization b9-1uH  0޽h ? 33t } 0   > (  ^  S @'J     c $ @ 0(   zPairwise Kruskall-Wallace Tests indicate significant difference in Median Hrs Service by CIS Level. In addition, Levels 1-3 are significantly higher than corresponding  levels in CIS prior to standards. However, implementation is still below recommended ranges as specified in standards. Relatively few cases in Levels 1 & 2 are actually getting the level of clinical service contact time outlined in the standards. This graph shows the median number of service hours/week for children in CIS and broken out by level of care. NOTE: 50% of children receive at least the median number of hours of service/week for each level. Now  this graph adds in additional information to show the degree of variation around the median # of hours/week  the bars represent the 25th and 75th percentiles of service receipt. Variation in service delivery is wider at Levels 1 and 2 and smaller for levels 3 & 4, indicating that the amount of service children receive on average is more consistent at the lower levels of care. 6.RH  0޽h ? 3380___PPT10.2'l~ 0 ,$(  ^  S @'J     c $@ 0(l  TL___PPT9.& VUpdated 7/13/05 Differences from Q I Relational Disorder (e.g., reactive attachment, parent-child relationship problem, maltreatment; 14% of children diagnoses).Was not computed in QI Smaller percentage of children diagnosed with mood (29 vs. 36% in QI), anxiety (11 vs. 15% in QI), and adjustment (19 vs. 23%). Maybe less likely to note internalizing difficulties in school. Axis I & II data missing for 7.8% of new admissions (largely east bay (n=8) and family services (n=28)) @+" +H  0޽h ? 33< 0 v(  ^  S @'J     c $@ 0(   This slide depicts how subgroups vary across the eight CAFAS subscales Mild Problems-low across scales Behavior Problems elevated on School, Home, Behavior, and Mood Community elevated on school, home, behavior, mood and community Substance Abuse elevated on School, home, behavior, mood and drug abuse Self-Harm elevated on School, Behavior, Mood and Self-Harm Additionally, subgroups differ by Demographic and Clinical Characteristics On this table, Subgroups listed across the top, demographic and clinical characteristics are listed on the right. Cell therefore indicate distinguishing demographic and clinical characteristics significantly different from other subgroups (From Brief) CAFAS subscale scores appear to be useful in identifying clinical subgroups among children exhibiting severe pathology, thus providing more depth and breath of information than global or uni-dimensional indices of functioning. Distributions of demographic and clinical characteristics across CAFAS subgroups highlight unique strengths, areas of need, and accordingly, potential areas and avenues for clinical focus. 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