Designing Care Management Entities for Youth with Complex Behavioral Health Needs

The Problem

Youth with complex behavioral health needs face a range of challenges and are at risk for poor health and education outcomes.^{1, 2} These youth are more likely to have difficulty forming friendships, drop out of high school, come in contact with the juvenile justice system, and attempt suicide than other youth.^{3, 4} Moreover, youth with complex behavioral health needs, especially those served in out-of-home placements such as foster care, are often taking more than one psychotropic medication, putting them at increased risk for adverse side effects, such as weight gain, high cholesterol, and diabetes.^{5, 6}

In addition, these youth are often served by, or come into contact with, multiple State and local agencies, such as:

• Medicaid.
• Social service agencies.
• Child welfare agencies.
• Behavioral health agencies.
• Juvenile justice systems.
• Schools and other education organizations.

These agencies may not always coordinate services and care planning for youth, due in part to poor communication channels, lack of comprehensive information, or concerns regarding confidentiality and privacy. Lack of coordination can reduce service effectiveness by agencies that inadvertently duplicate or even undermine each other’s efforts.^{7, 8}

When a child’s behavioral health and psychosocial needs are not addressed in a holistic manner, families may find themselves cycling in and out of crises. Youth in crisis may end up in out-of-home placements such as residential treatment centers, foster care, or juvenile detention centers. These potentially avoidable and restrictive placements separate youth from their families and communities and increase costs for the State.⁸

A Potential Solution: CMEs

CMEs are designed to coordinate services provided by the many State agencies that serve youth with complex behavioral health needs. The CME model was developed and continues to be refined as a strategy for serving the highest-need, highest-cost youth with complex behavioral health concerns, such as severe or co-occurring conduct, mood, and attention disorders. CMEs are intended to improve youth and family outcomes and to reduce the cost of behavioral health and social services for States.^{7, 9} They are also intended to help families better manage their children’s care on their own, with the goal of gradually reducing their reliance on intensive care coordination.¹⁰

Child-serving agencies, such as Medicaid, child welfare, social services, and juvenile justice can establish CMEs by contracting with a variety of organizations, including other public agencies, community-based nonprofits, behavioral health provider organizations, and managed care organizations.⁹ The number of CMEs States contract with varies depending on the number of youth eligible for CME services and the capacity of the CMEs.

CMEs employ or contract with care coordinators who typically support a maximum caseload of no more than 10 high-need, high-cost youth at one time. States can receive referrals for CME services from community-based organizations or child-serving agencies or analyze administrative data to identify high-cost, high-use youth. States often use a standardized screening tool, such as the Child and Adolescent Service Intensity Instrument (CASII), to determine if youth qualify for services.^{7, 9}

Once youth are enrolled in the CME, the care coordinator:

• Works with the youth and his or her family to identify a care planning team that includes service providers, State or local agencies, school representatives, and other natural supports, such as clergy.
• Facilitates care planning meetings.
• Facilitates development of an individualized, cross-agency care plan for each youth in collaboration with the youth, his or her family, and other members of the care planning team.
• Manages the individualized care plan for each youth.
• Facilitates the use of home- and community-based services, parent and youth peer supports, and crisis stabilization services in place of residential and inpatient care.Develops the youth’s and his or her family’s capacity and ability to solve problems independently.

To coordinate services, CMEs follow the high fidelity wraparound care-planning model outlined by the National Wraparound Initiative.^9-11 The term “wraparound” refers to an “intensive, individualized care planning and management process.”¹¹ The National Wraparound Initiative identified 10 principles that providers must follow to deliver high fidelity wraparound.

While all CMEs follow a similar care planning model, States can structure CME services differently. See Part 4 for more information on various CME structures.

Source: Ten Principals of the Wraparound Process¹¹

CMEs Impact Youth Outcomes and Costs

Youth outcomes

CMS and SAMHSA identified high fidelity wraparound as a promising model for serving youth with significant behavioral health concerns in the community.¹² Research on the effects of CMEs or other similar wraparound service programs have tracked outcomes for youth receiving wraparound services over time or compared their outcomes to youth receiving different services These studies found youth receiving wraparound services:^13-19

• Experienced less severe symptoms and improved clinical functioning.
• Were less likely to miss school.
• Were less likely to come into contact with the juvenile justice system.
• Experienced fewer days as runaways.
• Were less likely to change foster care homes.
• Spent fewer days incarcerated.

While promising, many available studies are limited by small sample sizes, short followup periods, and nonequivalent comparison groups. In addition, some studies concluded that CME-like wraparound services have limited benefits. For example, several studies found that wraparound services are more beneficial for some youth, such as those with the highest level of need, than others.^{18, 19} In addition, a study of a predecessor to the CME model found that although youth and their families were satisfied with demonstration services, clinical outcomes for youth did not improve.^{20, 21}

Cost

As with research on youth outcomes, research on the cost implications of CMEs is still evolving and relies largely on information reported by programs as opposed to rigorous independent evaluations. According to Maine’s wraparound initiative, total treatment costs 1 year after youth enrolled in the program were lower than costs for the year prior to enrollment. Other States and counties with CMEs have indicated that the average monthly cost per youth served is lower than the average monthly cost per youth served in an inpatient hospital, residential care, or a juvenile correctional facility.^{13, 16, 17, 19, 23}

In contrast, an early wraparound study showed that behavioral health service use and costs were higher for youth in the demonstration than for youth receiving traditional services, though the study did not take into account potential savings to other child-serving agencies.^20, Overall, cost outcomes have been difficult to assess because CMEs may produce measurable effects on such outcomes only after the relatively short followup periods covered in previous studies, and many cost studies do not include comparison groups.