This LWVMC Health Committee study was inspired by the perception of several League members in January 1999 that there were problems in the way mental health services for children and adolescents were being delivered in Montgomery County at that time. Although the study was first conceived as a fact-finding one only, at the League program planning meeting in January 2000 it was agreed that the study would include consensus questions. You will find the consensus questions on page FS-8 and a glossary of acronyms on page FS-7. We on the committee have talked with mental health providers, county officials, key people in a number of facilities where children with mental health problems are cared for, patient advocates, and personnel in the Montgomery County Department of Health and Human Services (DHHS). What follows summarizes our observations and impressions.

Montgomery County's public mental health system underwent a major upheaval two-and-a-half years ago when the Maryland Department of Health and Mental Hygiene (DHMH) implemented a new system of health care services for persons on Medicaid, the state/federal program that provides health care for the indigent. The program, then and now, is sometimes referred to as "Medical Assistance."

Under DHMH regulations that became effective on July 1, 1997, all persons who had been on Medicaid and some in the "gray zone" (the uninsured, sometimes also referred to as "the working poor") were moved into managed care. Those receiving mental health services were also included.

Prior to 1997 the county had operated eight public mental health clinics funded by the state through grants. Under the new managed care delivery system, payment would be on a fee-for-service basis and limited to treatment only. There was no guarantee that funds would be available to support the county-operated clinics. Therefore, in planning for the new public mental health system, the county developed a privatization model, building on the success of other effective public/private partnerships. Under this new system any registered provider can serve these clients. Privatization, it was believed, would not only be cost effective, but would offer consumers more choice in providers. The DHHS hoped over a period of two years to find private providers to manage all of its clinics. It was able to do so except for the Silver Spring clinic, which the county continues to manage.

Despite efforts to ensure a smooth transition to the new system, the upheaval at the beginning, particularly for emotionally disturbed children and adolescents, was little less than chaotic. Problems in the fee-for-services arrangement became apparent almost immediately, although a limited number of grants from the state became available to fill some unmet needs.

State: The Public Mental Health System (PMHS) was created when the Mental Hygiene Administration (MHA) within the DHMH merged the Medicaid system, which provides health care for the indigent, with the previous MHA grant-funding system. The new PMHS is based on a fee-for-service financial structure and is managed by Maryland Health Partners (MHP), an administrative service organization. MHP was contracted by MHA to expedite access to care, determine eligibility, authorize services and payments, and monitor system utilization across the state. It authorizes mental health services for those eligible for the PMHS.

A parent or guardian seeking help for a child may call MHA and speak to an MHP care manager, who will assess the childÕs eligibility based on two criteria. First, the child must meet medical-necessity criteria as determined by a preliminary assessment of clinical need using a standardized questionnaire. Second, the child must qualify financially either by being certified as Medicaid-eligible based on the level of the family's income related to its size, or by being identified as a "gray zone" child. If the child is eligible for services, the parent or guardian will receive a list of three or four possible providers. MHP has not followed up to see if the child has linked with a provider.

County: The Core Service Agency (CSA), located within the county's DHHS system, is responsible for planning, managing, and monitoring MHP services locally. It works to educate consumers, providers, and advocates about changes in the system. According to CSA data, 2,025 children and adolescents received some sort of mental health services in FY 1999.

The Access Team has been created to improve access to public mental health services. Its responsibility is to make available an updated list of providers with their specialization, location, and hours. There are plans to broaden this team to become a single point of entry to mental health services in the county. It will maintain an automated data system that will be useful to consumers and providers alike.

The Montgomery County Collaboration Council for Children, Youth, and Families promotes cooperative relationships among private and public entities that provide services to children and families in the county. The Collaboration Council, as required by state statute, serves as the Local Management Board (LMB) responsible for overall planning for the public and private service systems that support children, youth, and their families in Montgomery County. The Collaboration Council studies, advises, and recommends. It does not drive policy or appropriate or dispense money for services. It is concerned about how systems work. It studies federal, state, and local programs, and combinations of them i.e., Health Choice, the Children's Health Insurance Program (CHIP), Care for Kids, or other county programs for "gray zone" children. Its reports are considered unbiased and are widely respected.

The county has recently received a grant from the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA). This five-year grant with state and county matching funds will bring a total of $13 million worth of services to children and youth with serious emotional and behavioral problems, and is expected to greatly improve wrap-around services for these children. A Family Resource Team will be established in each public school "cluster" area served by a high school and its feeder schools. It will attempt to involve all of the significant people in a child's life Ñ parents, teachers, advocates, and therapists Ñ in developing a treatment plan for the child. Titled "Community Kids," it will provide services for 500 children over the next five years.

The Systems Review Initiative (SRI) has worked to bring children in out-of-state residential placements back to Montgomery County, where they are closer to their families. New initiatives aim at reducing dependence on out-of-home placements by developing a full continuum of community-based services and supports in the county.

State: The MHA funds mental health services for children and adolescents meeting medical necessity criteria for treatment only. It allocated approximately $30 million for children and adults in Montgomery County in FY 1999. While an exact breakdown is not available, a CSA spokesperson estimates that approximately 40% of the 5,000 clients served are children and adolescents. In FY 1999, in addition, the MHA granted $300,000 to provide these services to special populations (e.g., non-English-speaking children); to cover court-related costs for child welfare cases; and to fund a staff person for the Access team. Fees paid to providers for treatment hours have been increased and are now seen by some as fairly adequate, but providers' time spent on case management and in the juvenile court is still uncompensated.

County: Montgomery County itself budgeted $3,658,930 for FY 2000 for six programs focusing on prevention and early intervention and five specialized treatment programs. The former includes programs such as Linkages to Learning, the Crisis Center, and the Infants and Toddlers Program. The latter includes the Silver Spring Child and Adolescent Mental Health Clinic, among others.

In addition, the county budgeted $2,749,810 for contracted services with 27 private and public agencies, e.g., the Mental Health Association, the YMCA, Hotline, Jewish Social Service Agency, etc. In total, the county budgeted $6,408,740 for FY 2000 for operated and contracted services.

In spite of combined state and county funding, providers are still inadequately compensated for case management. At issue is how much the county should provide for mental health services if the state Mental Hygiene Administration fails to meet all of the needs.

Parents and families of children with mental health problems may seek help on their own, but frequently referrals come through the public schools. Teachers, school nurses, and other personnel of Montgomery County Public Schools (MCPS) may pick up on behaviors that parents have not recognized as problematic. Even if disabilities are "invisible," if they are serious enough to affect the student's educational program, parents are contacted and drawn into plans to try to identify the problem through testing, and treatment if indicated.

The school psychologist does testing within the school for out-of-mainstream education placement only. Children's disabilities are "coded" by intensity. Children coded with Intensity Levels 1-3 may be in regular classrooms, but identified for special help. Those coded "Intensity 4" are placed in special education. Those with "Intensity 5" are assigned to a special school, e.g., Mark Twain. "Intensity 6" requires a residential treatment center, e.g., the Regional Institute for Children and Adolescents (RICA).

In September 1999, there were 55 private psychologists in Montgomery County registered with MHP and eligible for reimbursement for psychological testing to establish diagnoses.

While children whose parents have insurance may be seen privately at first, private insurance usually covers a rather limited number of visits. If the problem is serious or complicated, the child usually eventually enters into the public mental health system.

What types of diagnoses do these children have? Attention deficit/hyperactivity disorder (ADHD), oppositional defiant, bipolar disorders, depression, anxiety, and conduct disorders are common. In general, providers attempt to use the least stigmatizing diagnosis. Most commonly, children with mental health problems have multiple episodes of short-term treatment. Within the past year, however, the schools have documented 209 "risk protocols," incidents in which the student exhibits either homicidal or suicidal behaviors. Of that number, 51 students required in-hospital treatment.

Outpatient services: CPC Health, Inc., serves from 600 to 800 children and adolescents in its clinics in Bethesda, Gaithersburg, Rockville, Wheaton, and its latest acquisition in Germantown, which was understaffed in February 2000 because of difficulty getting qualified providers upcounty. CPC Health is the county's major provider of mental health services, offering a full continuum of services. Its merger with Chestnut Lodge greatly strengthened its ability to serve this vulnerable population. An outpatient who needs inpatient hospitalization or group home partial hospitalization can be transferred quite quickly and easily. Its Wheaton outpatient clinic has a Latino program with nine licensed Spanish-speaking clinicians. The clinical director of CPC Health outpatient services takes pride in both the professionalism and the cultural sensitivity of his staff. CPC also has a special county-wide program for victims of trauma, abuse, and neglect that treats some 120 children.

Other providers of outpatient mental health services include Montgomery General Hospital's clinic in Colesville, Children's National Medical Center (Shady Grove Annex), Affiliated Sante Group in Silver Spring, Community Connections, Inc., Washington Assessment and Therapy Service, Family Trauma Services, Inc., and the Boys and Girls Home of Maryland.

Reginald Lourie Center for Infants and Young Children in Rockville is a private non-profit organization that specializes in assessment, treatment, and prevention of emotional and developmental problems of children from birth through 8 years. Diagnosis and intensive therapeutic family-centered treatment of young children is the center's hallmark. It sees some 1,000

children a year, about half of whom are referred by MHP. Many come from outside the county. Montgomery County presently contracts for treatment of 10 children in the Lourie Center Therapeutic Nursery. This nursery prepares at-risk three- and four-year-olds for later mainstreaming into MCPS kindergartes.

DHHS continues to manage the Silver Spring outpatient clinic in the absence of an appropriate private provider. The clinic is open 8:30 a.m. to 5:00 p.m., Monday through Friday, with evening hours available by appointment. It serves 150 children ages 5 to 17 years (frequently the most difficult cases from the juvenile justice system, child welfare, and foster homes) in addition to regular MHP referrals. It is often seen as the "provider of last resort." These children's problems are often difficult and complicated. The FY 2001 budget includes continuation of funding for the clinic, which should relieve the stresses felt by staff members concerned by the uncertainty of the clinic's future.

There are 140 private providers for children and adolescents on the MHP list, but they have not been as great a resource as might have been expected. They have no obligation to take these children, and problems of inadequate compensation, and sometimes unreliable and frequently difficult and complex patients, often cause them to limit the numbers of such patients.

Crisis services: All certified outpatient mental health centers and hospital emergency rooms provide crisis services. In addition, the Crisis Center provides 24-hour telephone, walk-in, and mobile outreach crisis intervention services to persons experiencing emotional or psychiatric crises. In crisis situations, it is sometimes the police who are called to intervene. The Montgomery County Police Department now offers its officers a course on how to deal with the mentally ill. Enrollment is voluntary.

Inpatient services, including residential services:

Chestnut Lodge, a residential treatment center in Rockville, is managed by CPC Health. It houses several specialized units for children and adolescents, most of whom stay for a week or two. These include the following:

Redl House, another CPC Health facility, is a group home for boys (ages 6-12) in Darnestown.

Charter Potomac Ridge offers short-term treatment for adolescents age 12 and up.

Charter Fairbridge, is a residential treatment center for children and adolescents in Rockville.

Regional Institute for Children and Adolescents (RICA) in Rockville is one of three RICAs in Maryland and is funded by the Maryland DHMH and the MCPS. It serves children from 6 to 18 years of age with severe emotional disabilities who come from Montgomery and nearby counties. Most students have multiple problems, and on admission 17-18% have alcohol and/or drug abuse as a secondary problem. Some 100 Level 5 elementary, middle, and high school students from Montgomery County attend the day school. The residential program (80 children) takes children from Montgomery, Carroll, Frederick, Howard, Prince Georges, and Washington counties. MCPS pays the educational costs of all day students, but only for Montgomery County students in the residential program. The annual cost per student is $24,613 for the day program and $73,644 for the residential one. The school has a fully accredited special education program that continues to nurture students beyond graduation when necessary. Its multi-disciplinary staff coordinates treatment plans. In addition to the education component of the program, students receive individual as well as family therapy. Most receive group therapy. The residential program provides an intensive 12-month a year, 12-hour a day treatment program for its Level 6 middle and high school students. They are housed in three cottages in units of eight each. Residential students usually stay in the program for roughly a year.

Linkages to Learning is a unique interagency collaboration between the MCPS, the DHHS, private nonprofit community agencies, faith groups, businesses, service and civic organizations, and volunteers. Its goal has been to alleviate social and family problems that undermine children's academic success. The program provides a broad range of services that include health, mental health, social service assistance, and educational support services in seven schools (five elementary schools, one middle school, and one alternative school) in Germantown, Gaithersburg, Silver Spring, and Wheaton. Each was chosen on the basis of the needs of its students, e.g., low income (measured by numbers of children receiving free or reduced-cost meals), immigrant status, and/or special education. Two of these, Broad Acres and Harmony Hills elementary schools, are comprehensive school-based health centers with a full array of health, mental health, and social services for children and their families. The Rocking Horse Road School Health Services Center, which serves as an entry point for international student admissions, is the program's eighth site. An effort is made to staff all of these centers with culturally competent, bilingual (when possible) people. All sites have mental health services, and the program is seen as a major piece of the mental health program on the prevention side. Linkages to Learning has been so successful that present plans call for expansion to 15 sites.

Mark Twain School in Rockville accommodates 200 middle and high school students with Intensity Level 5 emotional disabilities. It has one of the Linkages to Learning sites. The school's satellite program includes 150 students in Levels 4 and 5 at Magruder, Paint Branch, Whitman, and Quince Orchard high schools. Satellite programs are schools within schools. Each has between 30 and 40 students, three or four teachers, and four or five assistants. By the time the students have reached their junior and senior years, they may be mainstreamed three or four periods a day. Students at Mark Twain require more intensive external controls and may be on behavioral contracts. There are 40 students in its middle school (grades 6 through 8) and 160 in high school. Who are these adolescents? Two out of three live with a single parent, and one out of four parents works a second job. Twenty-four percent are on medical assistance or Medicare. Twenty percent are from the working poor, and 12% are without medical insurance at all. Fifty percent have been referred to Protective Services, with about 25% of those for sexual abuse. Two-thirds of them have been in difficulty with the law, often as runaways or because of out-of-control behavior. Sixty-two percent have experience with alcohol and/or drugs, and 80% have a family member with a substance abuse history. Approximately 5% of Mark Twain students were hospitalized last year, and multiple hospitalizations are increasing.

Mark Twain has a wide variety of mental health supports. They include a chemical dependency counselor; four CPC Health therapists who see 50 students; the Pathways Program, an alternative individualized program for six students; Rites of Passage for boys (based at Springbrook and featuring student and parent support groups and tutoring); two probation officers; two psychologists (for 350 kids); and one teacher and one instructional assistant for each ten students. A crisis support teacher works on consistent behavior, anger management, and conflict resolution. There is an alternative support class for students who have been suspended from school. A social worker works year round. Dr. Jack Robinson, Principal, says the number of students seen by therapists should be doubled Ñ 20 students are waiting for therapy. The average length of stay at Mark Twain is a year and a half. The goal is to mainstream out with a 90% attendance record and grade C or better.

The Mental Health Association, a private, non-profit organization, advocates in the mental health field. It offers seminars on a variety of mental health issues, and manages direct service programs in this field for people of all ages. The Core Service Agency contracted with the Mental Health Association in fall 1999 to do a needs assessment of the PMHS. Its comprehensive report, which included adults as well as children, was made public in March 2000. Its observations and recommendations closely paralleled ours.

NAMI-Montgomery County, part of the National Alliance for the Mentally Ill, supports, disseminates information to, and advocates for persons with mental illness. Its goal is to represent and serve families. It takes pride in its Children and Adolescents Program.

Montgomery County Federation of Families for Children's Mental Health, is a non-profit parent-run organization focused on the needs of children with emotional, behavioral, or mental health disorders and their families. The CSA has recently contracted the federation to do focus groups with parents. Again, the problems voiced by parents are included in the list below.

When Surgeon General David Satcher, MD,.PhD, issued a call to action in his report "Mental Health" issued in late 1999, he noted that approximately one in five children and adolescents experiences signs and symptoms of a mental health disorder during the course of a year, although only 5% experience what professionals term "extreme functional impairment." Preventive interventions, he notes, have shown to be effective in reducing risk factors, and a range of efficacious psychosocial and pharmacologic treatments exists for many children's mental disorders.

The cost of treatment for mental illness is high in both human and financial terms. But we believe that the investment of time, money, and commitment to prevent and/or treat these problems in the young pays off in terms of healthier, happier lives, more productive citizens, and reduced costs down the road. It is estimated that 30% of Montgomery County's homeless have mental health problems, as do 50% of the inmates in the county detention center.

We believe DHHS personnel are making a sincere effort to correct the obvious problems in our present public mental health system. Whether those problems inherent in the fee-for-service system can be resolved remains to be seen. Whether the state, and if not the state, the county, will provide the monies to meet these compelling human needs and whether the public will support the expenditure are other important issues.