From 1998 to 2009, the Children’s Health Initiative provided the research arm of a longitudinal study involving family driven community based intensive clinical intervention project called the Massachusetts Mental Health Services Program for Youth (MHSPY). Founded by Dr. Katherine E. Grimes, MHSPY is a nationally and internationally recognized model for integrated systems of care on behalf of children with serious emotional disturbance.
Initially sponsored as a two year pilot by the Robert Wood Johnson Foundation, the MHSPY program went on to become a twelve year demonstration project for innovations in:
Clinical delivery of children’s health services
Child mental health policy and governance structures, and
Health care financing
The MHSPY model is intended to maintain youth with severe functional impairment in the community via delivery of integrated primary care, mental health, substance abuse, and social services. The MHSPY program served children and teens in the towns of Cambridge, Somerville, Malden, Medford, and Everett who were referred by child serving agencies due to difficulties at home, school, and/or in the community.
Key features were coordinated, individualized, family-focused and community-based care delivered to youth and families so that children could live at home, stay in school, and continue to grow and learn. The MHSPY shared governance model included the State Departments of Medicaid, Children and Families, Youth Services (juvenile justice), Mental Health, and Education.
Outcomes derived from repeated measures of clinical functioning, service utilization, cost, and care experience from baseline to discharge were monitored and analyzed for over ten years by the CHI, with guidance from national experts on the CHI Advisory Group.
The MHSPY Process
MHSPY was designed to provide support to youth and families by surrounding them with resources based in their own communities. Our hypothesis was that the best way to support vulnerable children and adolescents was to identify an individualized group of formal and informal supports (i.e. caregivers, teachers, and doctors). These child and family resources were invited to participate in the child’s Care Planning Team.
The Care Planning Team met regularly to help identify the strengths and needs of the child, to set goals, and to implement and monitor customized interventions. All of the MHSPY participating agencies, including the Department of Children and Families (DCF), the Department of Mental Health (DMH), the Department of Youth Services (DYS), the Department of Education (DOE), and MassHealth contributed to the blended funding that was used to address the child’s needs. Each Care Planning Team was guided by a MHSPY Care Manager; Care Managers were experienced mental health professionals who also served as key contacts for community partners and MHSPY stakeholders.
The MHSPY clinical intervention combined mental health, pediatric and substance abuse services to maintain Medicaid youth with serious emotional disturbance (SED) in their homes and communities. The MHSPY study monitored results in four discrete outcome domains for children with serious emotional disturbance who were considered at-risk of out-of-home placement: (1) functional status, (2) utilization, (3) cost, and (4) care experience.
The study employed a longitudinal, multi-wave process using standardized measures of clinical functioning, service utilization, cost and satisfaction for children ages 3 through 19. Multiple standardized measures were administered to assess the overall level of functioning of the target population and identify the presence of change in mental health status at intake and every six months while the participant was enrolled in the program. These measures included the Child and Adolescent Functional Assessment Scale (CAFAS), Child Global Assessment Scale (CGAS), Child Patient Assessment Tool (PAT), ChildBehavior Checklist (CBCL), Youth Self Report (YSR), Teacher Report Form (TRF), Family Centered Behavior Scale (FCBS), as well as Family, Youth and Agency Satisfaction Surveys. Service utilization and expense data was also maintained on all medical services, including mental health and substance abuse, pharmacy, emergency room use, surgery, medication, and labs for all enrolled MHSPY youth.
Through MHSPY, these children received specialized mental health treatment (including psychiatric hospitalization and medication), comprehensive medical care (MassHealth Standard benefit, which included ER, inpatient, outpatient, etc.) and a variety of individualized, non-traditional services (such as family support) outside the Medicaid benefit. Together these resources enabled MHSPY graduates to attend school and live in their communities. Results from MHSPY’s final Contract Status Meeting in 2008 reported that:
88% of overall program days for youth were spent at home
Hospitalization rates during 12 mos. of enrollment were reduced 70% compared to the 12 mos. prior to enrollment; Residential Treatment settings use declined for the same period by 81%
Total medical expense (including hospital, ER, etc.) were 11% lower than those for the Medicaid Standard benefit reference group, 47% lower than Commercial, and 82% lower than for Medicaid Disabled
In addition to using fewer hospital days and costing less, MHSPY enrollees and their families were engaged in their care and showed significant clinical improvement. Clinical results and care experience findings across sites include:
Average overall improvement at 18 months in CAFAS scores was 22 pts., indicating clinical change
CAFAS Thinking score at 18 months improved 51%; Community Risk improved 31%
Lethality score at 24 months improved 29%; CGAS improved 17% at 24 months
Family Centered Behavior Scale indicated 96% of families felt their MHSPY Care Manager “helps them expect good things in the future for themselves and their children.”
Parents reported being “Satisfied” or “Very Satisfied” 86% of the time with the help they received
The drop-out rate for MHSPY was only 2% , despite enormous barriers to engagement
These results have been reliable across instruments and reproducible over time. They represent the combined efforts of the families and youth themselves, the dedicated MHSPY clinical staff, the inter-agency Care Planning Teams. These creative and resourceful teams were invaluable, and as were all the system partners who were willing to spend the “time it takes” (average length of enrollment was 20 months) to help each child and family practice pathways to health. Given the state’s challenge to improve identification and care for youth with serious emotional disturbance, the MHSPY model is a tested approach for providing maximal clinical cost-effectiveness within a strength-based, family driven system of care.