“The question is not whether we can afford to invest in every child; it ...

An Opportunity for Youth, Family
and Systems Outcomes
Center for
Innovative
Practices at
the Begun
Center for
Violence
Prevention
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“The question is not whether we can afford
to invest in every child; it is whether we can
afford not to.”
Mariann Wright Edelman
“It is easier to build strong children than to
repair broken men.” Frederick Douglas
• IHBT expands the continuum of care to increase
the availability of the less restrictive service
options for youth at-risk of out-of-home
placement due to behavioral health issues.
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Home-Based Delivery Model
Location of Service
Home and Community
• IHBT is an intensive, time-limited mental health service for youth with
serious emotional disabilities and their families, provided in the home,
school and community where the youth lives, with the goal of
stabilizing mental health concerns, and safely maintaining the youth in
the least restrictive, most normative environment.
• Comprehensive set of services (CPST; Behavioral Health Counseling
and Therapy; Crisis Response; mental health assessment; supportive
services) integrated by a team of providers into a seamless set of
services delivered to the family.
• Main Purposes:
• Placement prevention
• Reunification
• Stabilization and safety
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Intensity
Frequency: 2 to 5 sessions per week
Duration: 4 to 8 hours per week
Crisis Response & Availability 24/7
Active safety planning & monitoring Ongoing
Small Caseloads
4 to 6 families
Flexible Scheduling
Convenient to family
Treatment Duration
3 to 6 months
Cross-system Collaboration Child and Family Team Meetings
Supervisory Availability 24/7
Skillful Advocacy
Comprehensive Service Array
Promote accommodations and
protect rights
CPST, Individual and Family
Therapy, Crisis response, Assessment
System of Care Service Philosophy
Home-Based Service Delivery
Resiliency-Oriented Perspective
Multidimensional Assessment
Comprehensive Treatment Array
Matched to Needs and Strengths
• Youth with Serious Emotional Disturbance (SED) with
functional impairments
• Less intensive services were unsuccessful
• Multiple system involvement
• At-risk of placement due to safety issues
• Multiple risk factors; Few protective factors
• Skill set deficits
• Youth need additional supports, active facilitation, and
accommodations for success
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• Youth with serious emotional disorders
• At risk for out-of-home placement; or
• Returning from out of home placement; or
• Requires a high level of mental health interventions
to stabilize potential safety concerns
• Is under the age of 18; or
• Youth age 18 through 21 who are still living at
home and attending high school or under the
jurisdiction of another child serving system
• System has not engaged youth and family effectively
• Families who have difficulty with service access (work,
transportation, poverty)
• High stress – Low resource
• High family conflict
• Current parenting skill set unsuccessful in dealing with youth's
mental health needs
• Parents need significant levels of support (few external
supports)
• Trust issues with the “system”
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• Foster Care
• Therapeutic Foster Care
• Group Home
• Psychiatric Hospitalization
• Residential Treatment Facilities (Unlocked to
locked)
• Incarceration
• Homebuilders (1974): Original home-based model; often referred
to as family preservation; target population is youth at-risk for abuse
and neglect (length of stay- 4 to 6 weeks)
• Kaleidoscope (1973) Karl Dennis; wraparound model developed (no
eject no reject policy)
• Philadelphia Child Guidance Model: Structural Family Therapy
home-based therapy model
• Multisystemic Therapy (MST): EBP for juvenile justice 3- 5 months
• IHBT: Ohio’s intensive home-based treatment model: for youth with
SED who are at-risk of placement; returning from placement; or have
a significant safety/risk issue that potentially puts them at risk of
placement
• Integrated co-occurring treatment (ICT): for youth with co-occurring
substance use and mental health disorders (3 to 6 months)
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Home-Based Delivery Model
Location of Service
Home and Community
Intensity
Frequency: 2 to 5 sessions per week
Duration: 4 to 8 hours per week
Crisis Response & Availability 24/7
Active safety planning & monitoring Ongoing
Small Caseloads
4 to 6 families
IHBT
Services delivered in the home and
community
24/7 availability & response by IHBT
team
Outpatient
Clinic-based
No 24/7 availability by team
Flexible Scheduling
Convenient to family
Frequency & duration matches need
One hour weekly appointments
Treatment Duration
3 to 6 months
Flexible Scheduling
Appointments during office hours
Cross-system Collaboration
Child and Family Team Meetings
Lead role in service coordination
Limited opportunities for collaboration
Supervisory Availability 24/7
Small Caseloads 30
Skillful Advocacy
Comprehensive Service Array
Promote accommodations and
protect rights
CPST, Individual and Family
Therapy, Crisis response, Assessment
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Time-limited
Comprehensive mix of services
Services are ongoing
Therapy only
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IHBT
Services delivered in the home and
community
24/7 availability & response by team
Frequency & duration matches need
Flexible Scheduling
Lead clinical & service coordination role
Small Caseloads

• Intensity
• Strength-based partnerships
• Delivered in the home, school and community
• Small caseloads
• Crisis availability and response
• Safety planning
• System collaboration
• Flexible service delivery
• Time limited
• Frequency: 2 to 5 meetings weekly
(depends on stage of intervention: increased frequency
at beginning and during crisis periods; decreased
frequency near time of discharge)
• Duration: Length of sessions matches youth and family
needs and averages a total of 4 to 8 hours per week
per family
• Services are generally more intensive at the beginning
of treatment and decrease over time as the youth and
family’s coping skills develop
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• A minimum of 3 hours per week of IHBT service
which must include at least:
‣ 2 separate face-to-face contacts; and
‣ 1 contact with the youth or family.
• Total service time may include phone contacts and
collateral face to face contacts
• Be strength-based and family-driven, with the youth
and family regarded as equal partners with the IHBT
staff in all aspects of developing the service plan and
service delivery.
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• IHBT is provided in the home, school, and
community where the child lives and functions
• No more than 25% of total service time is
delivered in an office setting (per service, per
child)
• Small caseloads
• A maximum caseload, per FTE, averaging 8 or less
over any six month period sampled;
• Caseload per full time equivalent staff shall not
exceed 10 at any point in time.
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• Crisis response is available 24 hours a day, 7 days a week.
• Crisis response may be provided through written agreement
with another agency as long as one IHBT staff is accessible
to the provider agency, and is available to the client and
family as needed.
• Active safety planning and monitoring
• Family is involved and informed
• Each family receiving IHBT services shall be assessed for risk
and safety issues and shall have a jointly completed safety plan
that is available to the family and is instructive of steps to take
in the event of a crisis.
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• Pro-active cross-system collaboration and service
coordination
• IHBT providers establish collaborative relationships
with other child and family-serving systems with the
goal of enhanced service coordination across
providers and systems
• The service is flexible and individually tailored to
meet the needs of the client and family
• Appointments are made at a time that is convenient to
the client and family, including evenings and weekends
if necessary
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• IHBT is time limited and should not exceed 6
months length of stay.
• A continued stay review must be completed for
each client receiving IHBT beyond 6 months,
and every forty-five days thereafter.
• Providers are culturally competent and responsive to
the unique cultural, racial, spiritual and ethnic
differences of the families they serve
• Services are individualized and build on the strengths
of the child/family’s race, culture, and ethnicity
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• The rights and privacy of youth and families
are protected, and effective advocacy efforts
are promoted to assist the family in system
navigation
• Supervisor support and 24/7 availability is a
key aspect of successful IHBT
• Supervisor has a designated responsibility to
the team
• Pro-active consultation and full access are
integral components of supervision
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Engagement and Assessment
• Engagement (youth, family, & collaborative partners)
• Crisis Stabilization and Safety Planning
• Assessment
Treatment
• Evidenced-based individual and family treatments and
supports
• Skill Building, Skill Consolidation, and Generalization
• High engagement and intensity for first third of
services
• Medium intensity 2 nd third of services
• Last two to four weeks decreased intensity
with increased reliance on informal supports
Enhancement of Positive Support Network
• Linkages, Closure, & Follow-up
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• Shared burden- shared risk
• No single system can manage the multiple issues
of at-risk youth and their families alone
• Mutual responsibilities: we all play a role
•Youth and family
•Providers
•Child-Serving Systems
•Community (supports)
• Service delivered where the youth lives and functions: home,
school, and community at times that are convenient to the
family
• Access to information
–Family dynamics and interactional patterns
–Recovery environments
• Access to people
–Family
–School
–Court
–Community
–Natural supports
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• Access for interventions: implemented where behaviors occur
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• Least restrictive environment
• Treatment responsiveness and persistence
• Advocacy and protection of rights
• Integrated, coordinated, and comprehensive services
• Culturally and linguistically competent services
• Strength-based perspective
• Youth guided and family driven services
• Youth and family partnerships
• Services are responsive and delivered at a time that is
convenient to the youth and family
• Service intensity matches the complex and multiple needs
of each youth and their family.
• Providers “recognize that needs can be complex, that
change is sometimes very difficult to achieve, and commit
to a mutual process of extreme persistence in the delivery
of services and supports (VanDenBerg, 2002).”
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• Youth and families have access to comprehensive
service array
• Services are integrated and seamless to family
• Single Point of Clinical Responsibility: IHBT providers
take a lead role in facilitating the coordination of
formal and informal services and supports, as guided
by the youth and family.
• Cultural mindfulness
• Respectful humility
• Make no value assumptions
• Utilize family’s unique values and culture in
planning process
• Understand that youth’s peer group culture may
have different value set than family’s value set
• Resource and support building
• Risk reduction & asset promotion
• Facilitation of accommodations across life
domains
• Youth can remain in their homes and receive the
necessary behavioral health services needed for
community stability.
• Reduced out of home placements
• 86% in recent 15 site IHBT evaluation (total youth
served)
• Build developmental skill sets
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• Evidence shows that offering a full range of
community-based alternatives is more effective
than hospitalization and emergency room
treatment
• The Commission’s final report endorses the
expansion of home and community-based
services and the move toward the use of
evidence-based practices
President’s New Freedom Commission on Mental Health
State Months Post IFPS % In Home
Kansas 12 91%
Wayne Co., Michigan 6 88
Kentucky 12 87
Marion Co., Indiana 6 83
North Carolina 12 82
Missouri 12 79
Washington 6 77
Mean 84%
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• Randomly assigned high-risk families to either family
preservation services (home-based) or traditional child
welfare services including foster care.
• At 6 months after IFPS, 88% of children were living at
home compared to only 17% in the non-IFPS group.
• At 12 months, 93% of IFPS children were at home
compared to 43% of non-IFPS children.
Placements Avoided
• 86% of youth served, all at-risk of out of home placement, were
maintained at home and in the community at discharge
• 100% of youth ages 4 to 6 remained in their homes safely (all
PCSAO referrals)
School Success
• Passing grades increased from 65 to 77%;
• Disciplinary problems decreased from 68 to 49%;
Juvenile Justice Outcomes
• 50% drop in youth arrested (44% to 21%);youth on probation
(27.5 to 13%);youth detained (13.5% to 7.1%)
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60
50
40
30
20
10
0
34.3
21.4
Problems
37.4
50.5
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10.8 8.99
6.09
Functioning Hopefulness Satisfaction
p

What Cost Analysis Shows
• Estimate the present value of saving a
14-year-old high risk juvenile from a
life of crime to range from $2.6 to
$5.3 million (p. 25)
“Intensive Family Preservation Programs that adhere
closely to the Homebuilders model significantly
reduce out-of-home placements and subsequent
abuse and neglect. We estimate that such programs
produce $2.54 of benefits for every dollar of cost.”
Washington State Institute for Public Policy (WSIPP): (Miller,
2006)
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Placement Type
Average Cost Per Diem Annualized Cost System(s) Impacted
Foster Care Level IV $123.90 $45,224 Local Job and Family
Services
Group Home $125 $45, 625 Local Job and Family
Services; Juvenile Courts
Residential
Treatment (nonsecure)
Residential
Treatment (secure)
Juvenile
Commitment
$200.56 $73,204 Local Job and Family
Services; Juvenile Courts;
School Systems
$335 $122,275 Local Job and Family
Services; Juvenile Courts;
School Systems
$440 $145,200 (11.9
months)
ODYS; Local Juvenile
Courts
IHBT (per treatment episode) $7,000 to 10,000
Foster Care Level I (per year) $18,203*
Foster Care Level II $26,076*
Foster Care Level III $32, 237*
Foster Care Level IV $45,224*
Group Home $45,625*
Residential Non-Secure $73,204
Residential Secure $122,275
IHBT (average cost per treatment episode) $7,500 All
Incarceration $160,600
* Does not include Medicaid and Medicaid match costs for mental health services
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Information Calculation Cost Benefit
86% of 394 youth served
remained in the home (339)
Average cost of placement
$57,788
339 youth
X
$57,788 =
$19,590,132
IHBT Grant FY 08 & 09 (394 youth) 394 x $7,500 =
$2,955,000
Typical Case Rate for IHBT =
$7,500
55 youth placed 55 x $57,788=
$3,178,340
Average cost of placement
$57,788
394 youth served in IHBT Grant
FY 08 and 09
Cost saved minus cost of IHBT
and cost of youth placed
$13,456,792 divided by total
youth served (394)
Total Benefit (19,590,132 –
3,178,340)/Total Service Cost
(2,955,000)
$2,955,00
Total cost of
IHBT
$3,178,340
Total cost of
placement
For every ($1)
dollar spent in
IHBT
$19,590,132
Placement costs avoided
Total Benefit
$13,456,792 (for all youth
served)
$34,154 (Cost savings per
youth)
$5.55 is returned in placement
costs avoided
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• Over $16.4 million in placement costs saved at the
cost of approximately $3 million (IHBT for 394 youth)
• Total Cost Benefit over $13.4 million saved for 394
youth served (IHBT grant 2009)
• The total cost savings per youth is $34,154
• For every dollar spent in IHBT/MST there was a
return of $5.55 or 555% in placement costs avoided.
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• Technical Assistance is needed to maximize effectiveness of
IHBT
• Agency/program level funding requires more than Medicaid
• A uniform data collection system is necessary in order to
provide timely clinical feedback and track quality improvement
• Stakeholders/funders increasingly relying on data to make
financial decisions
• Multiple partners and multiple systems are needed to support
implementation
• High level training and ongoing coaching and monitoring of
fidelity
So, where is
Ohio on IHBT?
ODMH committed to adding IHBT to
Medicaid service menu by FY ‘13
IHBT workgroup completed its review
ODMH conducting rate setting exercise
Next Steps: Prepare SPA and submit to
CMS
Training and roll out
Current IHBT status
• Approximately 20+ certified IHBT sites
• 16 MST teams for 10 counties
• Other non-certified in home programs
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Patrick Kanary patrick.kanary@case.edu
Richard Shepler richard.shepler@case.edu
Center for Innovative Practices
Begun Center for Violence Prevention, CWRU
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