San Francisco Collaborative Provides Continuum of Care for Severely Mentally Ill Youth
The project was part of the Robert Wood Johnson Foundation (RWJF) Mental Health Services Program for Youth (MHSPY) Replication national program.
- The grantee developed a capitated managed care system of behavioral health services for emotionally disturbed children and their families, which it had piloted in the Family Mosaic project that had been developed earlier under a previous grant from the MHSPY program. The managed care system was available to all children throughout the City and County of San Francisco, including children who were in foster care.
- Outcomes included a decrease in hospital use of more than one-third, residential placements at one-half of projected rate, and re-arrests reduced by 28 percent.
RWJF supported this project through a grant of $911,622.
The state's MediCal program for mental health services (the California equivalent of the Medicaid program) drafted in 1993, separated, or "carved out" mental health services. The San Francisco Department of Public Health, Division of Mental Health became responsible for ensuring the delivery of mental health services to all San Francisco MediCal beneficiaries by the time the plan was implemented.
Under this plan, the funding for both private fee-for-service and county-managed MediCal mental health programs was to be consolidated under the administration of the county. This plan integrated two fragmented service delivery systems, and it gave San Francisco the opportunity to maximize the resources for community services.
To take advantage of the opportunities, the Division of Mental Health needed to shift from fee-for-service and cost-reimbursement models targeted to the most seriously mentally ill, to an at-risk capitation model aimed at containing costs and providing easy access, early intervention, and a continuum of care for the most severely mentally ill.
Among those who would join the mental health plan were 40,000 children, 32,000 of them receiving Aid to Families with Dependent Children (AFDC), recently renamed Temporary Assistance to Families in Need.
The State of California was a site of the original MHSPY program. In September 1995, it requested that the remaining funding in grant ID# 020244, its final MHSPY grant, be transferred to the City and County of San Francisco, consistent with the state's policy to provide counties with more responsibility.
In 1989, with funding provided by the State of California through an early MHSPY grant, San Francisco had created the Family Mosaic Project, a pilot capitation project within a system of care for children and youth with serious emotional problems who were at risk of out-of-home placement.
A project of the San Francisco Department of Public Health, Division of Mental Health Child and Family Services, Family Mosaic had demonstrated the potential of managed care, while at the same time exposing some of the bureaucratic barriers to fully implementing it within the public sector. The national program office decided to treat this project's efforts to develop capitated managed care for behavioral health services as part of the replication of MHSPY, even though the funding continued to be provided under the original program.
Since RWJF initially funded the program in 1989, more than 600 families with children at-risk of out-of-home placement have benefited from the Family Mosaic's flexible wraparound approach to getting children and families the services they need from a variety of agencies and other providers. Children enrolled in the Family Mosaic for a year experienced a decrease in hospitalizations and incarcerations and an improvement in school attendance and performance.
The Family Mosaic Project has become an integral part of the system of care offered by San Francisco's Division of Mental Health Services for children and youth. It serves as a model for much wider system reform:
- Family Mosaic's risk-adjusted capitated MediCal contract for 200 seriously emotionally disturbed children and youth at risk for out-of-home placement with the state was the division's first lesson in how to manage capitated funding. The division now has introduced capitated contracts in other parts of the mental health system and has encouraged wrap-around services throughout the system of care.
- The Family Mosaic's experience in recruiting and credentialing a provider network has established the framework for a larger network for the San Francisco Mental Health Plan.
- The Division of Mental Health now manages the credentialing, quality improvement, and authorization for providers serving children in foster care.
- A Title IV-E (a federal program that provides teacher and trainee grants to schools of social work to train social workers in the specialty of child welfare) training curriculum was developed and implemented for mental health workers emphasizing the needs of children in foster care. Services for children and youth were expanded through Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), a federal program established under Medicaid, through which federal funds are used to provide services to meet any condition identified through screening and diagnosis. It has increased the number of San Francisco children served on an outpatient basis by 25 percent.
- Dual-diagnosis services were integrated through dual certification of the largest adolescent facility in San Francisco.
- The Family Mosaic Project expanded to manage integrated health and mental services.
- The state established outcome measures that are used by the Family Mosaic Project as well as additional evaluation to demonstrate its effectiveness. They show:
- Hospital days are down by more than one-third.
- At any measured point in time, the number of children in local inpatient psychiatric units of state mental hospitals was down on the average from 21 to 6.
- Residential placements are one-half of the pre-project rate.
- Re-arrests have been reduced by 28 percent.
AFTER THE GRANT
The next phase is an expansion of the Family Mosaic benefit package. Enrolled families will receive health, substance abuse, and mental health services within a single plan of care that also incorporates the resources and responsibilities of partner agencies including schools, probation, and child welfare. The components of a plan are now in place for an integrated system of care for these children and families.
GRANT DETAILS & CONTACT INFORMATION
Family Mosaic Project: San Francisco Mental Health Services for Youth Project
City and County of San Francisco (San Francisco, CA)
Dates: May 1996 to April 1998
Project Director: Nancy Presson
(Transfer from ID# 020244)
Report prepared by: David Kales
Reviewed by: Molly McKaughan
Reviewed by: Marian Bass
Program Officer: Michael Beachler