The Brisbane Report, Nancy D. Feldman, J.D. for New Jersey Protection and Advocacy, Inc.
PART 1 -- BRISBANE IN THE OVERALL SYSTEM OF MENTAL HEALTH SERVICES FOR ADOLESCENTS
Failings in the System Force Reliance on Brisbane’s Role as a "Place to Wait"
The ideal for mental health service systems for children and adolescents and their families is community-based systems of care. This philosophy of community-based systems of care emphasizes:
Lucy Keating, the Assistant Director of the Division of Mental Health Services' Office of Children's Services, has described her view of mental health services for children and adolescents as a "technology" that is applied when the child needs services rather than a static "system of care." Key components of her vision of mental health care are that the appropriate care should be available wherever the child is and should last as long as it is needed, rather than having an artificial time period.
Under either model, New Jersey’s mental health care for children and adolescents falls short. The services available do not meet the needs of this population for a continuum of care of differing intensities based on the child's needs, but instead are fragmented, rigid, inaccessible and full of gaps. There are insufficient services on every level, especially for the adolescents waiting at Brisbane, the most restrictive setting, for appropriate treatment to become available. Overall, deficiencies and problems are aggravated by the State’s failure to integrate funding streams for juvenile mental health services across departments, divisions and government levels.
State Organization
In New Jersey government, authority over mental health services for children and adolescents is shared by multiple state divisions and offices, including in the Department of Human Services -- the Office of Children’s Services in the Division of Mental Health Services, the Division of Youth and Family Services (DYFS), and the Division for the Developmentally Disabled. Also involved in providing services are the Commission on Juvenile Justice in the Department of Law and Public Safety and the Division on Addiction Services in the Department of Health. While educational services are a critical component in the treatment of mentally ill youngsters, there is no central authority within the Department of Education to oversee or coordinate these services for children who are in non-institutional settings. Instead, special educational services for these children are provided through the over 600 local school districts.
Not only are the juvenile mental health services spread across different departments and divisions in state government, but the funding streams are separate. This separation of funding and authority can lead to fragmented, uncoordinated services and discourages collaboration. Assistant Director Keating noted, however, that there is generally good communication and cooperation among the different departments and divisions, but acknowledged the exception posed by the difficulty of dealing with the separate school districts.
Development and Allocation of Juvenile Mental Health Services
Case planning and funding decisions for new community programs at the county level are directed by the Youth Incentive Program. This program, composed of a county-based CART (Client Assessment Resource Team) and CIACC (County Inter-Agency Coordinating Council), is supposed to provide wrap-around planning and flexible funding for children and adolescents in need of mental health services.
There are 27 CART programs, with one or more in every county (Essex County has three teams). Each CART meets weekly or bi-weekly to discuss and coordinate needed services for individual youngsters. Because of funding limitations, CART programs have to prioritize their services and do not get involved in providing prevention or early-intervention services. The CART is required to focus narrowly on the population of mentally ill children and adolescents with the most extreme needs, those hospitalized at Brisbane, those in placement out-of-state, or those at risk of an extended residential placement. The CIACC, which includes representatives from all of the child-serving systems in the county, as well as state and regional representatives and parents, oversees the CART. This body sets service priorities, allocates funds and deals with policy.
The Children’s Coordinating Councils are also involved with planning and allocating mental health services for children and adolescents. There are three regional Councils and one statewide body.
Summary of Available Services
Screening and emergency services are available seven days a week, 24 hours a day, at emergency services departments of community hospitals. Children and adolescents whose mental health crisis continues to be acute go to one of the nine regional CCIS (Children’s Crisis Intervention Centers) centers. With 3500 admissions annually, the CCIS units provide screening, stabilization, assessment and short-term intensive treatment.
The CCIS centers were originally 28-day facilities. However, in recent years, the length of stay has been decreasing to 10 to 12 days. The change in the length of stay at the CCIS units is attributed to the pressure from managed care organizations to release the patients more quickly, as well as to improvements in medications that make 28-day stays unnecessary. Patients at the CCIS centers who are on Medicaid tend to stay longer than those with private insurance. Also staying longer are the youths involved with multiple systems who may, for example, have mental health problems combined with a developmental disability and be involved with substance abuse. These children are harder to place, especially if there is no family involvement. Upon release from a CCIS, these children may be on a waiting list for critical services, such as youth case management, partial care programs and other outpatient services, including medication management.
Patients who need continuing intensive psychiatric treatment after being in a CCIS unit can go to one of three intermediate-care units for placement from 30 to 90 days. An adolescent between ages 11 and 17, in need of long-term psychiatric hospital care, is committed to Brisbane, the only state psychiatric hospital for youth. This facility has approximately 90 admissions each year.
Upon release from Brisbane or another inpatient psychiatric facility, adolescents who need a structured residential setting may be able to obtain placement in one of the limited number of psychiatric community residences. These facilities serve up to eight youths in a group home setting, with an average length of stay of six months. Other psychiatric community residences serve children between 5 and 10 years of age and older youths who are making the transition from the children's mental health system to the adult system. Brisbane patients who are ready for discharge and need longer-term care (12 to 24 months) are placed in residential care -- private facilities that are funded by DYFS through contracts. Other less-intensive services are provided for mentally ill children and adolescents through group homes and therapeutic foster care, also funded by DYFS. Limited intensive home services are also available, with priority given to patients being released from the CCIS units.
Gaps in New Jersey’s System of Mental Health Care Leave Adolescents Waiting at Brisbane for Appropriate Services
Residential Care Services Inadequate
Adolescents remain at Brisbane awaiting a less-restrictive placement because the available residential treatment options do not address their needs. The population for residential treatment has changed, with adolescents currently in less-intensive group homes comparable to the youths previously served in residential treatment centers. Meanwhile, the current population in need of residential treatment is younger, more disturbed, more likely to have significant disabilities, more likely to have been sexually abused and more likely to come from homes with substance abuse problems than in the past. Since the enactment of Megan’s Law, which requires that the location of sexual offenders be reported to the community, even fewer residential programs than previously are willing to provide treatment for this population. Consequently, it is especially difficult to find placements for mentally ill adolescents waiting at Brisbane who have been adjudicated as sexual offenders. Older youths who are in transition from children’s mental health services to adult services are also extremely difficult to place.
At a time when the population of mentally ill adolescents seemingly is more in need of intensive residential treatment, the number of available centers in New Jersey is decreasing. The main reason cited for this loss of in-state residential treatment beds is that the reimbursement rate from DYFS is too low for in-state facilities to cover their costs. (Out-of-state centers are reimbursed at a higher rate.) Higher reimbursement rates are needed to provide incentives for in-state providers of residential treatment to expand their services. Also needed are more rigorous contracts requiring treatment that actually meets the needs of the adolescents and meets measurable outcome goals.
In Spite of CARTs, the System Remains Crisis-Oriented
The CART programs are not meeting the needs of adolescents who no longer meet the standard for civil commitment, but are still waiting to leave the restrictive Brisbane setting. Due to the lack of both resources and available mental health services, CART programs focus on those adolescents who are currently in crisis, rather than those who are now stable, but waiting at Brisbane.
In addition, the CART programs are not addressing the needs of the younger, more disturbed children who are among those most in need of mental health services.
Already involved with multiple systems, these younger children may have a range of neurological problems, a history of sexual abuse or substance abuse. They are more violent than in the past, and there is less family involvement. Rather than getting intensive mental health treatment through the CART early enough to prevent a crisis, these children, as well as older adolescents, cannot get help until they are actually in crisis and their needs are acute.
Lack of Appropriate Services for Adolescents Waiting at Brisbane Related to New Jersey’s Failure to Use Federal Medicaid Funds
New Jersey has failed to take advantage of several options that would allow the State, with an increase in state funding, to receive increased federal Medicaid funds for mental health services for children and adolescents. With these federal funds, New Jersey could develop additional treatment programs for the adolescents waiting at Brisbane for services. One of these Medicaid options, used by almost all other states, permits the use of Medicaid funds to provide treatment for mentally ill children and their families under the EPSDT (Early and Periodic Screening, Diagnosis, and Treatment) program, a prevention program for Medicaid-eligible children up to age 21. Other options, as noted in the recent recommendations of the Blue Plan Committee of the Children’s Coordinating Council, include the Medicaid Rehabilitation Option, which would give New Jersey more flexibility to obtain Medicaid reimbursement for community-based and in-home services, and the Medicaid Targeted Case Management Option, which would enable New Jersey to increase both the number of mental health case managers and the intensity of case management services.
In addition, the State has a very low Medicaid reimbursement rate for mental health services outside of hospitals and clinics. In providing mental health services for children and adolescents, New Jersey is still relying on the medical model of care that focuses on the illness of mental health problems. With this model, available care tends to be for acute crises, rather than being oriented toward long-term care that integrates treatment with supports, such as behavioral aides in home and school and respite care for the family.