Special Supplement Children’s Mental Health Initiative December 04, 2009 Seven Years of System of Care on Guam: Summary of Findings The system of care initiative on Guam began as a grassroots movement in the 1980’s in response to the recognition that the needs of children with serious mental health problems were being inadequately addressed. Many were being sent o for residential treatment. A significant milestone occurred in 2002 when the Guam Department of Mental Health and Substance Abuse (DMHSA) was awarded a six-year cooperative agreement b Substance Abuse and Mental Health Services Administration to establish Project I Famagu’on-ta (Our Children), Guam’s System of Care for children and youth with serious emotional disorders. From 2002 –2009, this federally funded program focused significant financial and human resources on developing and implementing Guam’s System of Care. The role of the Guam CEDDERS Children’s Mental Health Initiative (CMHI) Evaluation Team, which provided evaluation services to the project during this period, has been to examine and analyze the services and processes of the project and provide feedback to strengthen implementation strategies. The Evaluation Team also provided the supports to learn about the children and families served by this initiative, as well as the impact on Guam’s child serving agencies and systems. Descriptive and demographic data has provided a snapshot of some of the characteristics of youth and families served by I Famagu’on-ta. The majority of children referred to the program were male (74%), of Chamorro or Chamorro mix descent (77%), with an average age of 12 years. Although children came from all socio-economic groups, over 50% live in a household with an annual income of less than $15,000 and families face multiple, complex problems such as homelessness, lack of transportation and insurance, and medical problems. Further analysis of the demographic data reveals that children of Chamorro and Chuukese descent are overrepresented in Guam’s System of Care. It is also noteworthy that 74% of youth, who were referred to I Famagu’on-ta, had prior contact with Guam’s juvenile justice system, and for 77% of youth, conduct/delinquency problems were one of the reasons for their referral to I Famagu’on-ta. This suggests the need for a focus on prevention and early identification of children who are at risk for developing conduct disorders and delinquent behaviors. In addition, Guam youth reported nearly twice the level of suicide ideation and self injury as youth in other system of care sites across the country. This data is consistent with other Guam youth suicide data, suggesting the need for increased outreach, prevention, and early identification efforts in this area. Despite the problems children presented at intake, after two years, many showed improvements in their emotional and behavioral health and experienced positive outcomes in school, at home, and in the community. The percentage of youth with high levels of clinical impairment decreased from 77% to 52% after two years, and the percentage of youth reporting serious depression dropped from 21% to 13%. Page 2 Narrative Needed Data reported were collected using the Enrollment and Demographic Information Form (EDIF). N = 355. Footer: 2 | I Tellai Special Supplement | Children’s Mental Health Initiative (CMHI) | Page 3 What is especially promising is that the number of youth reporting suicide ideation dropped from 27% to 4% and the percentage of youth who actually attempted suicide dropped from 16% to only 4%. Time spent in school is an important indicator, and data has shown that children with serious emotional and behavioral disorders frequently have high levels of absenteeism. After two years, 52% of youth improved their school attendance and 44% improved their grades. The percentage of youth suspended from school dropped from 42% to 29%. Rates of delinquent and illegal behaviors decreased, and fewer youth were arrested, convicted of a crime, or incarcerated. Positive outcomes and family satisfaction were related to wraparound service planning and intensive care coordination provided by wrap coordinators, as well as the informal supports primarily delivered by family partners, who serve as para-professionals, providing peer-to-peer support and advocacy. Unfortunately, wrap coordinator caseloads increased significantly over the past year, and it is unlikely that intensive wraparound care coordination can continue to be provided unless additional staff resources are made available. Further, the majority of the wrap coordinators and family partners are in unclassified positions and it is unclear if there is a plan to move these individuals into classified and permanent positions. Family partners have assisted families to secure job skills and employment, find housing and transportation, and have provided much needed “after hours” advocacy and support. While these are not what we consider “typical” mental health services, the evaluation data demonstrates that the informal supports provided by family partners played an important role in families achieving positive outcomes and satisfaction with services. Positive outcomes achieved at the service and program level included increased awareness of the needs of children with mental health disorders and increased knowledge of system of care values, principles, and practices. Collaborative partnerships among front line providers have been strengthened, resulting in more coordinated and integrated service delivery for children and families. New services were developed including: individualized services planning using the wraparound approach; intensive care coordination provided by I Famagu’on-ta wrap coordinators; day treatment through the Rays of Hope program; and the opening of Latte Treatment Center, an on-island therapeutic group home for children with more intensive needs. The establishment of Latte Treatment Center was especially significant in addressing the community’s concerns over off-island residential treatment and facilitating the return of children who were in off-island placement prior to the grant. Five children, who were in off-island placements at the time of the grant award, have returned to Guam. Only one youth was sent off-island during the past seven years and has since returned to Guam. Despite these accomplishments, Guam’s service array is still very much incomplete, and many services remain difficult to access. Significant barriers to expansion and sustainability of the service array include: Government of Guam personnel policies, job classifications, and procurement procedures; lack of appropriately trained personnel; inadequate local workforce development; and the timely payment of private contractors. At the systems level, a notable outcome was the establishment of the Guam System of Care Council (GSOCC) by statute in 2003 as the advisory body for Guam’s system of care. Consistent with system of care values and principles, the majority of Council members are families, and in the past year, Council membership was expanded to include youth representatives. Unfortunately, funding to support the operations of GSOCC was exhausted in 2008 and additional funds have not been made available. This has impacted the Council’s ability to perform its functions. Over the past seven years, Guam’s families of children with serious mental health needs have become increasingly empowered and organized. In 2004, Guam Identifies Families’ Terrific Strengths (GIFTS), Guam’s parent organization for children with mental health needs, was established as a 501(c)(3) non-profit organization, and as a local chapter of the Federation of Families. During the past year, GIFTS has begun playing an increased role in providing training to families and the community, and is working closely with the courts to provide family support. Several key policy makers, including members of the Guam Legislature and Judiciary, have increased their awareness of the needs of children with serious emotional and behavioral disorders and have become more educated about the importance of supporting children’s mental health services and advocating for a systems of care approach. Increased awareness among members of the Legislature resulted in $750,000 in local appropriations specifically to I Famagu’onta in fiscal years 2008 and 2009. However, I Famagu’on-ta has had difficulty accessing these funds. Within the Judiciary, two of Guam’s judges, who routinely see youth with serious mental health needs in their courtrooms, have become strong system of care advocates, applying the wraparound process and a therapeutic approach to the youth and families that appear before them. Interagency efforts were challenging, particularly as related to creating a cross-agency infrastructure that is essential for a fully functioning, sustainable system of care. Two cross-agency collaborative bodies, the Ombudsmen and the Executive Commission, were initially established to address infrastructure development, sustainability, and braiding and blending of resources. However, some anticipated outcomes and crucial cross-agency agreements and processes were not realized. Data suggests the following contributing factors: (1) lack of clearly defined roles and responsibilities; (2) competing priorities within the individual agencies, including DMHSA’s involvement in a Permanent Injunction for adult services; (3) changes in leadership within DMHSA and other agencies; (4) concerns over the impact of the initiative on individual agencies’ operating budgets; (5) lack of understanding and commitment to system of care values and principles; and (6) a perceived lack of understanding and buy-in related to individual agency roles within the system of care initiative. Despite these challenges, given the many significant positive outcomes achieved through I Famagu’on-ta, continued development and sustainability of Guam’s System of Care is essential. However, building and sustaining a system of care will not be achieved by a single agency or program. It is crucial that cross-agency and family driven collaborative structures (i.e., GSOCC, Executive Commission, and Ombudsmen) be revitalized and/or restructured, and that system of care values and principles drive decisions at all levels. Cross-agency policies and procedures are needed to increase availability, accessibility, and flexibility in the provision of services; and innovative strategies (e.g., blended, funded, cross-training, and assignment of staff, etc.) for sustaining Guam’s System of Care need to be formalized through an interagency Memorandum of Understanding. Building and sustaining a comprehensive system of care is complex and remains an unfinished task. It is important to build upon lessons of the past to guide future actions. Lessons learned from the evaluation of I Famagu’on-ta will provide useful information upon which the community will base future decisions. For more information about the evaluation of I Famagu’on-ta, or to obtain a copy of the final evaluation report, please contact Bonnie Brandt at 735-2398 or via email at bonnie.brandt@guamcedders.org. Bar Chart: Arrests, Crime Convictions, and Incarcerations Decrease Page 6-8 Timeline: Guam System of Care Initiative Milestones leading to the gradual shift from traditional service delivery to a community-based, culturally competent, and youth/family-driven System of Care 1980s * First child sent to off-island facility * Department of Mental Health & Substance Abuse (DMHSA) facilitates Strategic Planning to develop a comprehensive Community-based Plan for Adults’ and Children’s Mental Health Services * Department of Public Health & Social Services (DPHSS) implements Family Preservation Philosophy in service delivery 1990s * Inter-Agency Case Review Committee (IACRC) consisting of DMHSA, Department of Education (DOE), DPHSS, Superior Court of Guam (SCOG), and Department of Youth Affairs (DYA) was established to oversee off-island placements * Establishment of Child & Adolescent Services Division (CASD) under DMHSA * Department of Youth Affairs (DYA) begins shift from incarceration to community rehabilitation model with outreach and aftercare and prevention focus * Hawaii’s Ohana System of Care program provides Technical Assistance to Guam resulting in the formation of a collaboration group for developing a System of Care for Guam * Stakeholders participate in SAMHSA funded System of Care Policy Academy in Maryland 2000 * P.L. 25-141 establishes Guam System of Care Council (GSOCC) and provides $75,000 to support System of Care development * Project Filak I, under University of Guam Center for Excellence in Developmental Disabilities Education, Research, & Service (Guam CEDDERS), builds awareness about System of Care and Wraparound * Parents Reaching Out for Children Experiencing Emotional Disturbance (PROCEED), a support organization for families with children who have disabilities is established * Superior Court of Guam develops Juvenile Drug Court with its emphasis on treatment and rehabilitation vs. incarceration of youth with substance abuse problems 2002 * PROCEED receives Family Network Grant * Project Filak Phase II Pilots Wraparound with Interagency MOU * GSOCC submits System of Care Development Plan to Guam’s application for the SAMHSA funded Children’s Mental Health Initiative (CMHI) Cooperative Grant * Guam receives the CMHI grant award to fund local systems development via I Famagu’on-ta, Our Children * Local System of Care Community monthly meetings begin for awareness building 2003 * National System of Care Community Meetings in Portland, Oregon and Tulsa, Oklahoma * Outreach to families begins via village meetings, surveys, orientation * Site office established in the community at Ladera Towers, Mangilao * Social Marketing begins with family involvement (KGTF video production, resource binders, Wrap brochures, presentation posters, fact sheets, etc.) * Families begin involvement in planning and policy development committees * Local cash match $250,000 established by the Legislature for use in System of Care service delivery * Identification and enrollment for services of eligible youth and families begins * Renewal of Interagency MOU to support System of Care in Guam * Legislation re-establishes Guam System of Care Council with the mission to continue systems building Text in colored box: Training and T.A. Activities for 2003 * Leadership Training for program managers and families in Santa Fe, New Mexico * CMHI Technical Assistance Partnership Visit by Kate Pahinui & Regina Hicks * TA with Statewide Family Networks in cooperation with PROCEED Board members * TA on strategic planning for array of services with consultant Jody Lubrecht implemented three times during the year * Participation in the Cultural Competence Leadership Training, Washington D.C. * Training and consultant visits on family involvement by Debbie Toth-Dennis implemented three times during the year * Participation in Federation of Family Conference in Washington D.C. * Participation in Training on Case Management in Tennessee 2004 * 1st Federal Site Visit * National Systems of Care Community Meeting * 1st System of Care Assessment Site Visit * Relocation of Community-based site to Hagåtña * Day Treatment Services begins through Rays of Hope * Regional Meeting in Oakland, CA with stakeholders’ participation * Cultural & Linguistic Competence Committee established * TV series promoting I Famagu’on-ta airs on KUAM TV8 * 1st Family Partner hired (two more hired in 2005) Text in colored boxes: Training, T.A. & Conference for 2004 * Wraparound by Mary Grealish implemented (Parts I-IV) * Participation in the 1st Annual Family Involvement Conference in Missouri * National Evaluation Orientation and Training on National Longitudinal Study * Federal Technical Assistance Visit by Kate Pahinui Youth & Family Involvement Activities for 2004 * 1st Annual Youth Leadership Conference * G.I.F.T.S. Inc., (Guam Identifies Families Terrific Strengths) family organization established as 501-3C * Family Advisory Council Meetings begin * Family Resources Center opens in Mangilao * Family Support Group Meetings begin * Grandparents’ Support Group starts 2005 * 2nd Federal Site Visit * Therapeutic Group Home (Rays of Hope) opens * System of Care Community Meeting in Dallas * Therapeutic Group Home outsourced to Latte Treatment Center * Development of Project’s Sustainability Plan facilitated by Kate Pahinui, TA Text in colored boxes: Training, T.A. & Conference for 2005 * Training on Group Home Development and Behavioral Management by Dr. Valdes * Family Leadership Training with Family Peer Mentor TA Partnership * Behavioral Management Training with Mary Grealish & Dr. Valdes * Training on Therapeutic Foster Care and Respite Care, Part I & II by Mary Grealish Youth & Family Involvement Activities for 2005 * Family Advisory Council Meetings continue * G.I.F.T.S. receives non-profit status * G.I.F.T.S. becomes chapter of National Federation for Children’s Mental Health * G.I.F.T.S. hosts National Federation of Families Conference, Washington, D.C. 2006 * 3rd Federal Site Visit * System of Care Regional Meeting in San Diego Sustaining System of Care, Building and Maintaining Collaboration through Strategic Finance Planning * 2nd Annual Children’s Mental Health Awareness Week * System of Care Community Meeting at Georgetown Training Institute in Orlando, Florida * National Evaluation 2nd Site Visit * GSOCC adopts Sustainability Plan * GSOCC continues monthly meetings * Outreach provided to 31 schools from GPSS Text in colored boxes: Training, T.A. & Conference for 2006 * Technical Assistance & Training from Hawaii’s Tina Donkervoet to the Executive Commission on Policy Development * Workshop on Sustainability by Kate Pahinui * Trina Osher Policy Development Training for Families * Training on Foster Care Treatment in Pittsburgh * Staff Training on CAFAS Part I & II * IDEA Training by Trina Osher * School Based Mental Health Training in Baltimore with Trina Osher * “Transforming Mental Health in the Pacific Islands Conference” Youth & Family Involvement Activities for 2006 * Publication of G.I.F.T.S.’ Newsletter: Family Matters * 3rd Youth Leadership Conference at Guam Hilton Resort & Spa * Parent Professional Partnership Training with Barbara Huff and Richard Donner * Training for families on “Telling your Story” by Barbara Huff & Jane Tobler * Federation of Families on Children’s Mental Health Conference in St. Louis 2007 * Guam Legislature appropriates $750,000 in local funds to support I Famagu’on-ta for FY2008 * System of Care Community Meeting in Atlanta, Georgia * 1st of 4 round table discussions with Guam’s policy makers with participation by families and program staff * Ombudsman Meetings * Executive Commission Meetings * GSOCC Monthly Meetings continue * National System of Care Meeting in New Orleans with stakeholders Text in colored boxes: Training, T.A. & Conference for 2007 * Training on Rays of Hope and Therapeutic Group Home * Participation in Child Physical and Sexual Abuse Conference * Staff Training on Ethical Decision Making Youth & Family Involvement Activities for 2007 * Federation for Families Conference Conference on Children’s Mental Health in Washington, D.C. 2008 * System of Care Training Plan completed by Guam CEDDERS * GSOCC Monthly Meetings continue * Guam Legislature appropriates $750,000 in local funds to support I Famagu’on-ta for FY2009 * National Evaluation Site Visit Assessment on System of Care * 1st Regional System of Care Conference “Transforming Children’s Mental Health in the Pacific Islands: Celebrating our Progress, Sharing our Knowledge and Promoting the Strengths of the Family” Text in colored boxes: Training, T.A. & Conference for 2008 * Staff Training on Court Etiquette * Staff Training on Supportive Employment with EEO staff * USF Research Conference in Tampa, Florida * Staff Training “National Crime Victim Rights Week” * Staff Training “Child Maltreatment for Multidisciplinary Professionals” Social Marketing/Outreach Activities 2008 * Panel Presentation at the Annual NASW Social Workers Conference with Judge Barcinas * 4th Annual children’s Mental Health Week * Legislative Public Hearing on Bill 302 to fund I Famagu’on-ta * Parent Outreach at Agana Shopping Center with GPSS * Presentation to the Guam Developmental Disabilities Council (GDDC) * Presentation to the (Ropes Group) Judges from Supreme Court and Superior Court 2009 * TASI (Transitioning Adolescents Successfully to Independence) program is piloted * Transition Focus Group is conducted * National System of Care Community Meeting in Anaheim, CA with youth participation * Portland State System of Care Conference with youth participation * YES (Youth Enhancement & Support) is established as a 501-3c * G.I.F.T.S. conducts training in schools & provides peer-to-peer support to court involved families * Guam CEDDERS Evaluation Team sponsors a Digital Stories Workshop for Youth * Children’s Mental Health Evaluation Summit * 2nd Annual System of Care Conference * I Famagu’on-ta sponsors Fidgety Fairy Tales Musical Page 8 Youth Produce “Digital Stories” Storytelling is an important tradition in The Digital Stories were showcased at the Children’s many cultures and can be a powerful way to Mental Health Evaluation Summit held on September document one’s experiences about a specific 16 and will be used in future events to demonstrate the program. On June 8 – 12, Guam CEDDERS CMHI I Famagu’on-ta Evaluation Team sponsored a Digital Story workshop as a closure activity for the Youth Evaluation Team. Four youth, ages 16 – 19, who were receiving or had received I Famagu’on-ta services, participated in the workshop conducted by off-island consultant, Jana Sczersputowski. As part of the Digital Story workshop, youth were asked to identify a turning point in their life and to create their own personal story of how they turned a challenge into a success. They were involved in all aspects of creating their digital story, from recording it in their own words, to selecting music and images to help portray the events in their stories, to learning to use the computer software to incorporate all the elements. The Digital Stories were showcased at the Children’s Mental Health Evaluation Summit held on September 16 and will be used in future events to demonstrate the positive impact of I Famagu’on-ta on the lives of the youth it serves. Quote: “Building and sustaining a comprehensive system of care is complex and remains an unfinished task.”