Dr. Young is affiliated with the Department of Psychology, University of Mississippi at Oxford, Peabody Hall, University, MS 38655 (e-mail: jnyoung1@olemiss.edu). Ms. Plotner is with the Mississippi Division of Medicaid, Jackson. Dr. Damon and Dr. Hight are with Mississippi Children's Home Services, Jackson. Fred C. Osher, M.D., is editor of this column.

In 2006 the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, began an initiative to study community-based alternatives to residential treatment for youths with severe emotional disturbance (1) and their families. This led to the dispensation of grants to ten different states for the purpose of conducting demonstration projects examining this topic. The Mississippi Division of Medicaid was among the grant recipients, and the state government matched a portion of the funds acquired, bringing the amount allocated to this project to $66,000,000. Resource expenditure was apportioned to two phases: an initial 20-month period wherein the project is implemented in a smaller scale across the state (with $5,000,000 being expended) and a subsequent three-year period in which lessons learned in the first phase will be used to revise the program and enroll greater numbers of participants by using the bulk of project funds. This column provides an overview of the project and its goals.

The major purpose of this project (entitled Mississippi Youth Programs around the Clock, or MYPAC) is to create, maintain, and disseminate system-level policies and practices that result in meaningful improvements for Mississippi's youths with severe emotional disturbance and their families. Meaningful improvements are operationally defined in terms of measurable changes in real life, with the particular goal of promoting functional abilities among youths served. Consistent with the initial model outlining basic premises of systems of care (2), the project is guided by the a priori assumption that it is better to serve children in their home communities than in restrictive residential placements.

Achieving the goals of the project necessitates changing current policies directing the course of care for Mississippi's youths with severe emotional disturbance, including revising traditional administrative and clinical conceptualizations of service delivery. The state has always sought to serve youths in the least restrictive setting possible; however, the determination of what is possible, particularly when the youths served live in remote rural areas without a strong local system of care, has generally been psychiatric residential treatment, necessitating the removal of youths from their homes. As an alternative, MYPAC is enrolling willing participants in a 1915(c) demonstration waiver program, such that normal qualifying requirements of Medicaid service provision can be waived, particularly those regarding eligibility for certain funding levels. MYPAC participants can receive a level of funding for community-based treatment commensurate with what the Mississippi Division of Medicaid would normally pay for residential treatment (that is, approximately three times as much as typical outpatient care), but instead of receiving restrictive residential placement, they receive wraparound services (an approach to service delivery that integrates multiple domains of youths' lives [3]) in their home communities.

In many cases, particularly in very rural areas of Mississippi, some creativity is necessary to effectively reach families. In these cases, the project has earmarked funds to acquire in-home therapists who travel to the youths' homes, establish telehealth services in youths' local (or nearby) community mental health centers to enable psychiatric consultation, and provide Web-based delivery of some services. Additionally, 24-hour crisis intervention and stabilization services will be offered to all families. These services are seen as critical to enabling youths with severe emotional disturbance to be maintained in their home settings.

The goals of MYPAC could not be met without a strong partnership between public-sector and private agencies. After the grant was funded by the federal government, the Mississippi Division of Medicaid began accepting proposals from community agencies to act as service providers. Criteria for selection of agencies included an established system of care (that is, a comprehensive array of tiered services, arranged in a sequence of progressive intensity, ranging from fairly time-limited outpatient treatment to residential or acute psychiatric care) and the ability to provide services throughout the state, a clear understanding of relevant scientific literature, and a demonstrated history of effectiveness in serving youths with severe emotional disturbance.

Currently, the Mississippi Division of Medicaid is working with the two community agencies chosen as providers to accomplish the goals of the study. The Mississippi Division of Medicaid identifies potential project participants meeting the following intake criteria: being younger than 21 years, having a severe emotional disturbance classification, and either residing in a residential placement with a desire to transition out or being qualified for residential treatment and wanting to remain in the community. These individuals are then connected to a local community mental health center, which provides an initial comprehensive evaluation. Community partners are provided with copies of the community mental health centers' assessments, which are used as a foundation for treatment planning and integration of youths into the project. Providers also serve as care coordinators for study participants, arranging for seamless integration of all necessary services, including (but not limited to) psychotherapy, medical care, respite, and nontraditional services that support any of the above. The program has been in operation since November 2007 and has enrolled approximately 100 participants to date. Over the next five years, it is expected that approximately 1,470 such youths will be served in the course of the project.

Assessment

An important aspect of MYPAC is assessment of outcomes for all participants. Participants are monitored for functional and symptomatic change over the duration of treatment involvement, which is expected to be approximately nine months in most cases. [A table with the instruments used in the MYPAC project and an appendix with the entire Modified Monthly Treatment and Progress Summary instrument are available as online supplements at ps.psychiatryonline.org.] Follow-up measurements will also be taken at given intervals posttreatment, so as to allow understanding of participants' functioning and outcomes after services have been concluded. Additionally, a comparison sample will be selected from among existing state residential treatment populations (balanced for age, gender, and ethnicity in comparison to the treatment sample) and will undergo identical assessment procedures. Costs for services rendered in both samples will also be compared as a primary outcome for the study, with the expectation that community-based services can be rendered at the same or reduced costs as residential care. This variable is seen as critical to shaping future policy change, given that the long-term effectiveness of any program of services is irrelevant without cost-effective, feasible implementation strategies.

Treatment

Treatment services include regular, in-home contact with families, with exact services being determined on a case-by-case basis as appropriate to ensure therapeutic progress (that is, procedures are not manualized). In a way, the lack of prescribed therapeutic structure and lack of specific reliance on evidence-based techniques supported by scientific literature is not ideal, because it limits replication and deployment to other settings. Alternatively, this "treatment as usual" approach affords an opportunity to understand more about the content of services delivered in real-world, unconstrained settings. In order to achieve this understanding, this project uses an instrument designed to codify specific aspects of services rendered (that is, targets and practice elements) (4). This instrument is a modification of the Monthly Treatment and Progress Summary (5) and the Service Guidance Review Form (6), which are widely used for recording specific aspects of treatment in the state of Hawaii. Each month every therapist in the study will complete a short checklist concerning services rendered for each client.

Over time as participants show improvements, it is expected that intensity of services will be diminished. The algorithm for approximate length of time necessary for MYPAC treatment was generated on the basis of calculating the duration and number of person-hours typical in residential treatment by using local aggregated data collected through one of the providers. These services have been demonstrated to be effective over time in this setting, and so they were used as the benchmark to determine what treatment "dose" might likely be necessary for effective community-based care.

Although this column is but a brief overview of activities associated with MYPAC, the implications of this work are important for public policy nationally. Nine other states received similar grants, and as data from these projects become available, changes to service provision are likely to result. To the extent that community-based care is shown to provide the same or better outcomes as residential care at equivalent or reduced costs, we can expect administrators, policy makers, and family advocates to engender a movement toward this model of service provision. Comprehensive understanding of these issues now, at the front end of likely system change, will be beneficial to the field at all levels.