Keeping Youth at Home, in School and out of Trouble: Mobile Response and Stabilization Services in the New Jersey System of Care
Guenzel, Jeffrey J., Vietze, Alan, Davis, Wyndee O. G., Policy & Practice
New Jersey is the nation's most densely populated state, containing the 10th largest population of children and youth in the country. In 2000, the state set out to transform its children's mental health system. This effort, which implemented services in January 2001, addressed a very broad population of children--those with serious emotional disturbances as well as those at risk. It included children eligible for public health insurance programs (Medicaid and Family Care--New Jersey's State Children's Health Insurance Program--have carved out behavioral health services from physical health care services and coordinated benefit packages) and children whose private insurance would not cover the services they needed. This system transformation was designed with the values and principles of the System of Care (Stroul and Friedman, 1986) as its operating framework. Its purpose is to ensure that children and families receive the services and supports they need, when and where they need them, so they can remain at home, in school and out of trouble. The state created new infrastructure components, services and supports, policies and procedures and has realigned existing ones. Now integrated with New Jersey's Child Welfare Reform Plan, this transformation effort operates under the Department of Children and Families.
(Like many states, New Jersey's Child Welfare Agency is under a court settlement necessitating numerous child welfare system reforms. New Jersey's Plan, "Child Welfare Reform Plan: A New Beginning" July 2004, includes children's behavioral health as a critical component requiring among other things the closure of the state's only children's psychiatric hospital.)
The development of the System of Care (SOC) grew out of a parent/professional endeavor that led to the award of a SAMHSA grant in Burlington County. The grant for the Burlington County project served as the springboard for developing a statewide SOC model. With the support of the governor, who allocated seed money and revamped the Medicaid State Plan for Children's Mental Health that would bring children's mental health services to the Medicaid platform, New Jersey proceeded.
Some key components of the New Jersey SOC include a wraparound care management entity that addresses the complex needs of multi-system-involved youth and a mobile response and stabilization component designed to provide face-to-face crisis intervention in the community within one hour. Other features include a family support organization designed to provide peer support for caregivers, and intensive in-community treatment provided by licensed clinicians in children's homes or other community settings. Each of these services is managed by the state but operated by local agencies at the county level.
Out-of-home residential treatment programs have also been dramatically changed since the reform began. New Jersey has moved away from institutional care and has developed many small community-based homes for youth that previously would have been "placed" in institutional residential treatment centers. In addition to the newly developed array of community services, a key component of managing the SOC is an Administrative Service Organization or Contracted Systems Administrator in New Jersey. It serves as the single point of entry and provides utilization management and standardized electronic records for the SOC.
Over the next five years the state seeded all communities/counties with the continuum of services. Over time both processes and practices have been refined and programs addressing specific needs were developed. Some addressed the specific needs of the juvenile justice system, medically fragile youth and youth with co-occurring developmental disabilities and mental health challenges. Today the SOC serves nearly 40,000 children and youth annually in New Jersey and has been successfully keeping youth at home, in school and out of trouble.
While success has taken an entire SOC with multiple initiatives and services, the Mobile Response and Stabilization Service (MRSS) has been a key component in this effort. Being able to respond to escalating behaviors--within an hour--in the community and being able to provide up to eight weeks of stabilization services in a youth's home, has helped the state realize many positive outcomes through our SOC.
Mobile Response and Stabilization Services
Mobile Response and Stabilization Services (MRSS) were designed as one integral part of the New Jersey SOC Initiative to provide community-based crisis response. The intervention is intensive, therapeutic and rehabilitative. MRSS programs provide assessment, evaluation and follow-up services to youth up to the age of 21 experiencing escalating behavioral and emotional health challenges. Youth and their families seeking these services often feel out of control, have exhausted available resources, and need additional resources and skills to help with their circumstances. The goal is to stabilize the youth and family and to maintain youth in their home and community. Service outcomes include managing risk, minimizing disruptions in homes and communities, improving life domain functioning, maintaining living arrangements, and avoiding unnecessary psychiatric screening, hospitalization and foster care placements.
MRSS is grounded in SOC values and principles, which are applied in interventions, assessments, planning and service delivery. There is a fundamental belief that youth with emotional and behavioral challenges have the greatest opportunity for normal healthy development when ties to community and family are maintained.
Access to MRSS is available 24 hours a day, 7 days a week and is obtained through a statewide toll-free number for the Contracted Systems Administrator (CSA). The CSA determines intensity of need and makes all initial referrals to MRSS. The practice model relies upon local agencies to provide timely community responses and local stabilization networks.
Initial MRSS services include a community-based intervention (typically in a home or school) by trained mental health professionals delivered within one hour of an initial request. The goal is to restore baseline functioning by addressing primary presenting issues and underlying needs, and to inhibit cycling of crisis episodes. Interventions are grounded in crisis and systems theory and rely on successful engagement, relationship building, an understanding of youth and family dynamics and the application of wraparound values. Staff conducts comprehensive assessments across life domains, which include identifying needs and behavioral triggers. The Crisis Assessment Tool (CAT) was designed for MRSS to communicate assessed needs, drive planning and evaluate outcomes. Youth and family strengths are identified and used to develop strategies for recognizing and managing triggers to avoid further crisis episodes. An Individualized Crisis Plan (ICP) is developed that delineates needs, goals, strategies and desired outcomes. MRSS team members deliver and coordinate all necessary services and supports identified in the ICP for up to 72 hours and may deliver face-to-face interventions and telephonic coordination during this time. In addition, services that may be helpful, but are typically not covered by health insurance, are encouraged to help the family manage the crisis. State funds support these efforts to address needs creatively.
Stabilization services are provided by the agency for up to eight weeks following the initial response to support the individualized crisis plan implementation. Services available are delivered in the community and include intensive counseling services, behavioral assistance, psychiatric consultation, stabilization beds, outpatient mental health services and informal supports.
MRSS Lessons Learned
Even though the fundamental planning for MRSS was sound and the program that exists today is very much the same program that was designed more than 10 years ago, there still have been lessons learned and adjustments that have been needed.
MRSS programs have a positive reputation throughout the state based on their ability to respond immediately with a quality of service that has successfully maintained 95 percent of youth within their homes, schools and communities. MRSS programs outcomes rely heavily on existing as part of New Jersey's larger comprehensive SOC and benefit from closing system service gaps such as access to outpatient psychiatry and community-based therapy.
The utilization of MRSS has steadily increased post-implementation. Most of the state's other service lines have leveled out over the past 10 years with only minimal changes from year to year. In the case of MRSS, the state has needed to make more dramatic adjustments to MRSS resources due to demand.
MRSS was conceived to serve a majority of youth with a high acuity of need. While MRSS met the demand of serving the system's most acute youth, data demonstrated that youth accessing MRSS reflected a broader range of need. There has also been a marked increase in dispatch requests for youth with co-occurring developmental disabilities that require specialized interventions. As a result, the state implemented a specialized training component for MRSS programs and increased system coordination efforts in response to this need.
When the SOC was conceptualized, "crisis stabilization beds" were designed as an option of last resort to allow time and space for youth and families working with MRSS to maintain living situations. It was thought that these beds were critical for the MRSS program. However, where these beds were developed, utilization was low and eventually the beds became non-existent. This was not expected. We believe the immediate response and wide array of community services have been the reasons the beds were no longer necessary.
Family Support Organization services were not designed to be offered to families accessing MRSS. However, a recent performance improvement project demonstrated that linkage to Family Support Organizations for families that demonstrated moderate to high social support needs yielded a decrease in MRSS recidivism.
Over the last 10 years, New Jersey's SOC has made incredible strides in improving care for youth with emotional and/or behavioral challenges. We have been very successful in meeting the goals set forth in the concept paper for the New Jersey Children's SOC Initiative. While the success is the result of a comprehensive system, the MRSS has been a key component for New Jersey in reaching the goals it set for the initiative.
For example, more youth are served in the community and not in out-of-home treatment settings than ever before. We have closed institutional residential care facilities, including the state's only state-operated child psychiatric hospital and, most recently, the last three state-operated residential treatment centers. Serving youth in the least restrictive setting possible has continued to improve in recent years. Since 2007, we have decreased the number of youth in out-of-home care by an additional 15 percent. Our initiative to return children to New Jersey from out-of-state facilities has been remarkably successful--only nine youth are currently in out-of-state residential treatment. This is a 97 percent decrease from the approximately 350 youth that were in out-of-state placements prior to launching the initiative.
In addition to the fact that SOC is able to successfully serve more youth in the community rather than in out-of-home treatment centers, the youth being served in out-of-home settings generally stay in the programs for shorter lengths of time and show better outcomes.
Our community-based programs have been very successful in supporting youth in the community. On average, 95 percent of youth accessing MRSS are able to be successfully supported in their current homes.
In addition, there are far fewer youth in juvenile detention facilities than when the SOC began, which resulted in the closure of multiple juvenile detention centers throughout the state. While the SOC cannot take full credit for this change because there are other juvenile detention alternative initiatives in place in New Jersey, we believe that because of the SOC, youth with emotional and behavioral challenges are getting more appropriate interventions through our SOC rather than ending up in detention facilities.
The New Jersey wraparound programs have also been very successful in serving youth with the most complex needs. Care management programs, combined with the MRSS, have led to a 50 percent decrease in re-admissions to child psychiatric inpatient units and successful diversion from the usage of inpatient treatment.
Family involvement has also been very successful. Families have reported being consistently active participants over time and satisfaction rates have been steadily increasing.
It is the belief of the Division of Child Behavioral Health Services that adherence to the values and principles of our System of Care, combined with quality and effective programming like the Mobile Response and Stabilization Services, has resulted in the success of our program over the past 10 years.
Jeffrey J. Guenzel is the director of the Division of Child Behavioral Health Services at the New Jersey Department of Children and Families.
Alan Vietze is the assistant director of the Division of Child Behavioral Health Services at the New Jersey Department of Children and Families.
Wyndee O.G. Davis is the MRSS coordinator in the Division of Child Behavioral Health Services at the New Jersey Department of Children and Families.…
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication information: Article title: Keeping Youth at Home, in School and out of Trouble: Mobile Response and Stabilization Services in the New Jersey System of Care. Contributors: Guenzel, Jeffrey J. - Author, Vietze, Alan - Author, Davis, Wyndee O. G. - Author. Magazine title: Policy & Practice. Volume: 69. Issue: 5 Publication date: October 2011. Page number: 22+. © 2008 American Public Human Services Association. COPYRIGHT 2011 Gale Group.
This material is protected by copyright and, with the exception of fair use, may not be further copied, distributed or transmitted in any form or by any means.