2014 APA Bronze Achievement Award: A Family-Focused Partnership to Engage High-Risk Children and Adolescents in Services

As systems and practices across the country seek to integrate behavioral health services into routine primary care, some are encountering children and families with complex needs that cannot readily be addressed by typical integrated programs. Children and families who live in or close to poverty often experience significant stress and trauma and have few supports or resources. Many have no insurance and no medical home. Some children have endured years of repeated foster care placements. Others have escaped intolerable family situations for the “freedom” of life on the streets. Many have learning disorders, problems with aggression, and involvement with other systems, such as child protective services, special education, and the juvenile justice system. Brief psychiatric assessment or consultation is not enough. To achieve the best outcomes, primary care practices need to partner with an agency that can work to engage and stabilize these children and families so that they can benefit from treatments and services.

LifeWorks Shared Psychiatric Services (SPS) is such an agency. It is based in three Austin locations (East, South, and North) because of the high concentration of disadvantaged families in those areas. The program is not limited to office locations and can expand to community and home as needed. SPS was created in January 2011 as a pilot program involving three collaborating agencies: Communities in Schools of Central Texas (www.ciscentraltexas.org), SafePlace (safeplace.org), and LifeWorks, the lead agency. Families are referred to SPS by the three agencies. SPS provides psychiatric diagnosis and treatment, care coordination, and case management, with the goals of transitioning the child and family to a medical home or long-term provider and a payer source (insurance or Medicaid) and preventing escalation and costly treatment. LifeWorks SPS uses a strengths-based, family-focused approach to promote self-sufficiency and empower children and families to develop goals and make the best use of services. Care is free of charge, and critical resources, such as bus passes, reduced-cost prescriptions, and medical laboratory tests, are provided.

In recognition of its innovative, family-focused approach to creating a pathway to stable, long-term care for hard-to-reach families, LifeWorks SPS was selected to receive APA’s 2014 Bronze Achievement Award. The award was presented October 30, 2014, at the opening session of the Institute on Psychiatric Services in San Francisco.

SPS services, staff, and funding

LifeWorks SPS uses a brief, solution-oriented approach in which well-trained staff promote a language of hope and positive expectations during intake and assessment and throughout services. Services are geared toward building a solid relationship with and providing services to every family member, including adults who may have postponed their own care. To create the SPS program, LifeWorks derived some inspiration from the well-established Massachusetts Child Psychiatry Access Project (MCPAP). In addition to the consultative model of MCPAP, SPS has a strong basis in family systems and trauma-informed care. The model at its core is based on a motivational, collaborative, client-driven aspirational approach as articulated by Hubble, Duncan, and Miller. The SPS program also recognized that child and adolescent well-being is inexorably linked to the well-being of the parent or caretaker. This was based on internal analysis and published evidence that parents’ mental illness and substance abuse predicts poor adherence to recommended treatment for children. Both Division Director Anita Jung, L.P.C., F.A.P.A., who developed and implemented SPS and trains professionals internationally, and Clinical Care Director Julie Speir, L.C.S.W., who trains professionals in trauma-informed care, have improved services by focusing on a motivational approach to engage families in a meaningful way. Since 2011, SPS has built a multiagency, multidisciplinary collaboration—including psychiatrists, public school staff, primary care physicians, therapists, and case managers—all focused on supporting youth and families.

LifeWorks SPS serves a predominantly Latino (60% Mexican and Mexican American) and African-American (15%) clientele. Bilingual clinical care staff (clinical care specialists, clinical volunteers, and SPS interns) screen new clients and provide initial consultation before contact with the psychiatrist, information about the SPS program, and routine follow-up regarding medication side effects and treatment compliance. The clinical care director trains and supervises staff and interns. The two psychiatrists contracted to work with SPS are board-certified adult and child and adolescent psychiatrists. Each psychiatrist has experience working with marginalized populations and a commitment to community-based integrated care.

SPS psychiatrists see patients in three LifeWorks clinics and in the Safe Place emergency shelter for victims of trauma. They also conduct home visits. The psychiatrists provide children, adolescents, and families with urgent or routine care (not emergency care), including assessments, diagnosis, prescription and monitoring of medications, parent education about illness and medication, staff consultation and training, patient advocacy, and consultation with other professionals (such as pediatricians). The psychiatrist does not provide psychotherapy for the child or family.

In the 2013–2014 annual funding cycle, SPS served 302 clients. Sixty-four percent of the clients who did not have a medical home at program entry were connected to a medical home upon case closure. At program exit, 94% of families reported improvement in the primary presenting issue and symptoms. SPS has greatly improved access to psychiatric consultation. Time to first psychiatric visit is one to two weeks, which is highly unusual for this geographic area.

LifeWorks SPS is funded by St. David’s Foundation in Austin, which has supported LifeWorks since 1998. In fiscal year 2014, the foundation provided $516,000. Revenue from insurance in 2014 is expected to be around $24,000. Fiscal year 2015 is funded at $485,000 from foundation money, and expected revenue from insurance is $50,000.

Executive Director Susan McDowell. M.A., is the social entrepreneur and lead driving force behind LifeWorks. LifeWorks is an Austin-based nonprofit organization that was founded in 1998 as a result of merger of four nonprofit organizations. The agency operates eight service sites, employs 180 staff, utilizes more than 500 volunteers, and has an operating budget of $10.7 million. LifeWorks provides a safety net infrastructure to ensure that basic needs are met, including food, clothing, health, shelter, and behavioral health care. LifeWorks serves more than 6,000 area families annually through a network of 20 housing, counseling, education and workforce, and youth development programs. All programs are aligned in a collective impact continuum to support youths, young adults, and families in their efforts to achieve measurable increases in self-sufficiency—the mission of the organization.

Overcoming challenges

In building an effective program, LifeWorks SPS has overcome several challenges. Finding medical homes for uninsured clients as they transition from the program has been particularly challenging. SPS psychiatrists and case managers have personally talked with primary care physicians and have urged clients to make appointments, providing them with bus passes or cab vouchers when needed. Psychiatrists consult with the primary care physicians, who monitor clients’ medication regimens when they leave the SPS program. Assurance from the SPS psychiatrists that ongoing consultation is available to the physician has been instrumental in securing medical homes for many clients.

“No-show” clients and those who cancel appointments have also been an issue. To increase utilization and decrease costs, SPS created a wider pipeline of referrals and started to accept families with health insurance coverage if they fit the focused profile of the client population, which helps streamline referrals. In addition, SPS now accepts self-referrals of individuals who meet the target profile.

To increase nonfoundation revenue, SPS has focused on obtaining third-party reimbursement. It identified common insurers and certified providers for the insurers’ panels, advocated with insurers for higher reimbursement rates, and increased the efficiency of enrolling uninsured clients.

Measuring outcomes

LifeWorks SPS uses several methods to measure the effects of the program, including intake data and routinely collected outcomes data, client satisfaction surveys, and the Arizona Self-Sufficiency Matrix. LifeWorks employs an in-house director of research and evaluation, Elizabeth Schoenfeld, Ph.D. In addition, program and business operations evaluations have been conducted by independent parties. Feedback from an external evaluator in February 2013 prompted SPS to implement several program changes to improve service delivery and client outcomes. Specifically, a motivational interviewing–style readiness assessment was introduced to the referral process, allowing better identification of clients who are ready for services. In addition, SPS trained and recommended that partner agencies infuse referrals with a language of hope and positive expectations, and staff also introduced a client action plan, allowing clients to track their own progress. Approaches have been tailored to each individual family, following concepts introduced by Milton H. Erickson, M.D., to maximize results and engage families rapidly and effectively.

Using an adaptive and innovative approach, LifeWorks SPS has succeeded in enhancing the positive effects of the collaborative care model, harnessing the resources, energies, and commitment of community agencies to help high-risk children and families achieve greater stability, the foundation for healthy development and healing.

For more information on program design, implementation, and evaluation, contact LifeWorks SPS Division Director Anita Jung, L.P.C., F.A.P.A. (e-mail: [email protected]). For more information on SPS operations, contact Clinical Care Director Julie Speir, L.C.S.W. (e-mail: [email protected]). To learn more about LifeWorks, visit the Web site (www.lifeworksaustin.org).