# Presentation: 732865

## Understanding Child and Adolescent Users of Targeted Case Management Services in Maine: An Exploratory Study

- Paper presented at the 16th Annual Research Conference: A System of Care for Children’s Mental Health: Expanding the Research Base
- James T. Yoe, Ph.D.
- Winston Turner, Ph.D.
- Julia Burns, MSW
- Sapna Linus, MS
- March 2-5 2003

## Study Questions

- What are the demographic and diagnostic characteristics of children and adolescents served in Targeted Case Management Services?
- Can distinct subgroups of children and adolescents be identified based on demographic, diagnostic, behavioral/functional, and service use characteristics?
- To what extent do functional/behavioral outcomes and service use differ for these identified child/adolescent subgroups over time?

## Study Sample Selection Criteria

- Sample of 492 children and adolescents enrolled in Targeted Case Management Services in FY 2000 and FY 2001
- All study participants were enrolled in case management services for at least 12 months with functional/behavioral assessments completed at baseline, 6 months and 12 months
- All active Medicaid Service recipients with at least some service use during FY 2000 FY 2001 or FY 2002

## Study Data Sources and Measures

- Service Utilization: Medicaid Service Claims FY 2000 to FY 2002
-    - Targeted Case Management (Annual Units & Cost)
-     - In-Home Support Services (Annual Units & Cost)
-     - Crisis Intervention Services (Annual Encounters & Cost)
-     - Residential Treatment Services (Annual Units & Cost)
-     - Inpatient Psychiatric Hospital (Annual Episodes, LOS &  Cost)
- Child & Adolescent Characteristics: Medicaid Claims/Child Assessment Data
-    **-** Age at Baseline
-     - Diagnosis
-     - Gender
- Functional/Behavioral Outcomes: Child Assessment Data
-     - CAFAS Assessments at Baseline, Six months and 12 months
-     - CALOCUS Assessments at Baseline, six months and 12 months

## Full Study Sample Characteristics N=492

**Gender: **69% Male
**Age:  **Average Age  12.19: Range: 4.27 to 18.89 Years
**Primary Diagnosis **
- 	       Adjustment Disorder          2.5%
-               Anxiety Related                  4.0%
-               Conduct/Oppositional       19.5%
-               Trauma Related                 12.8%
-               Attentional/Impulse           26.2%
-               Depression Related            11.9%
-               Bipolar Illness Related       10.5%
-               Psychotic Disorders             2.5%
-               Other Diagnosis                 10.1%
-               Missing Diagnosis               9.1%

## Full Study Sample Characteristics (Continued) 

**Level of Functional Challenge**
**       ****- **Average CAFAS Youth Score at Baseline:  87.42
-          CAFAS Levels at Baseline:
-              0 to 10   	 No Challenges   		 1.0%
-             20 to 40   	 Mild Challenges                                  13.8%
-             50 to 90   	 Moderate Challenges                          44.3%
-         100 to 130   	 Marked Challenges                             28.0%
-         140 & Higher	 Severe Challenges		12.8%
-        - Average CALOCUS Composite Score: 19.64
- 	10 to 13	Level   I 		                 	 4.5%
- 	14 to 16	Level  II			 2.7%
- 	17 to 19	Level III			26.3%
- 	20 to 22	Level IV	 		 8.4%
- 	23 to 27	Level  V			49.6%
- 	28 & Higher	Level VI			  8.4%

## Cluster Analysis Summary of Methods

**Cluster Variables:**
**	****- **Youth Age at Baseline
- 	- Gender
- 	- Diagnosis Categories:
- 	 Conduct/Oppositional	 	Trauma Related
- 	 Attentional /Impulse Control	 Depression Related
- 	 Major Mental Illness (Bipolar and Psychosis Related)
**Service Use – Cost: Three Year Composite Cost Variables computed for each of five service areas (FY 2000; FY2001; FY2002)**
**	****- **Targeted Case Management	- Inpatient Psychiatric Hospitalizations
**	****- **Crisis Intervention Services 	- Residential Treatment
- 	- In Home Support Services
**Baseline CAFAS Total Youth Score & CALOCUS Composite Score**

## Cluster Analysis Summary of Results

## CAFAS Total Youth Scores by Child Cluster Over Time

## CALOCUS Composite Score 

- by Child Cluster Over Time

## Summary of CAFAS Subscale Changes by Cluster Over Time

- School/Work Role – No significant improvement over time, but Clusters I and III have significantly higher challenges than Cluster II.
- Home Role – Significant functional improvement over time with Cluster II showing greatest functional improvement. Clusters I and III have significantly higher challenges than Cluster II.
- Community Role – Significant functional improvement over time with all Clusters showing improvement. All Clusters differ significantly, with Cluster III having the highest functional challenge in this area.

## Summary of CAFAS Subscale Changes by Cluster Over Time (Continued)

- Behavior Toward Others – Significant improvement over time, with Cluster I showing the greatest improvement, and Cluster III the least.
- Moods-Emotions – No significant change over time. Children in Cluster I and III show significantly higher challenges than Children in Cluster II.
- Self-Harmful Behavior – All groups score low on challenges in this area. Significant time effect with all groups showing improvement. Cluster I and III show significantly higher challenges than Cluster II.

## Summary of CAFAS Subscale Changes by Cluster Over Time (Continued)

- Substance Use – All Clusters have low functional impairment in this area. There is a significant time effect with all Clusters showing increasing use.
- Thinking – No significant change over time. Cluster III children exhibit the highest level of challenge in this area, and Cluster II children the lowest.

## Summary of Selected CALOCUS Subscale Changes by Cluster Over Time

- Risk of Harm: Significant improvement over time with Children in Cluster I and Cluster III have significantly higher risk scores than children in Cluster II and exhibit greater improvement over time.
- Functional Status: Significant improvement over time with Cluster I children showing the most improvement and Cluster III children the least improvement.
- Co-Existing Conditions: Low frequency of co-existing conditions across all child clusters.  No significant change overtime or differences between Clusters.

## Summary of CALOCUS Subscale Changes by Cluster Over Time

- Resiliency and Treatment History – No significant change over time.  Children in Cluster III exhibit significantly higher functional challenges compared to children in Cluster I and II.
- Environmental Stress - No significant change over time. Cluster III Children shows significantly higher functional challenges in this area than either Cluster I and II children.
- Environmental Support – Significant time and between Cluster effects with children in Cluster III exhibiting significantly greater challenges in this area and greater deterioration over time compared to children in the other two Clusters.

## Summary of Selected CALOCUS Subscale Changes by Cluster Over Time (Continued)

- Combined Child/Parent Engagement – No significant time effect. Children and parents in Cluster III have significantly higher treatment engagement challenges compared to their counterparts in Cluster I and Cluster II. Treatment acceptance and engagement challenges show an increasing (deteriorating) trend for Cluster III children and parents.

## Average Annual Number of Hospitalizations  

- by Cluster Over Fiscal Years

## Average Hospital Days 

- by Cluster Over Fiscal Years

## Average In-Home Support Days

- by Cluster Over Fiscal Years

## Average Crisis Hours

- by Child Cluster Over Fiscal Years

## Average Residential Days

- by Child Cluster Over Fiscal Years

## Study Conclusions

- Based on demographic, diagnostic, functional challenge, and service use characteristics, three clinically relevant subpopulations of children and adolescents were identified and described from current recipients of Targeted Case Management Services in Maine.
- These subgroups of children and adolescents were found to differ substantially in their use of service system resources and in their response to treatment and supports over time.
- This study identified a potentially important subpopulation (Cluster III) of child and adolescent users of Targeted Case Management that appear to be resistant to treatment, have more complex clinical profiles, are more likely to have experienced trauma, and are heavy users of high cost system services and resources, and show minimal behavioral/functional improvements over time.

## Study Conclusions

- Targeted Case Management Services in combination with intensive In-Home Behavioral Support services appears to be most effective with younger children with moderate to severe behavioral challenges and generally less complex clinical profiles.
- The findings of this study suggest that the presence of previous trauma experience contributes to poorer treatment outcomes and with increased use of high cost and restrictive services. These findings raise serious questions regarding the ability of child and adolescent systems of care to adequately identify, assess, and provide effective treatment to child and adolescent trauma survivors.

## Areas Needing Further Study:

- Need for more focused studies of the effect of untreated trauma on treatment effectiveness and outcomes for children and adolescents with behavioral and emotional challenges.
- Comparative studies examining the service use and cost implications of untreated trauma in children and adolescent users of system of care services.
- Further study of the child, family, and service system factors associated with poor treatment outcomes along with the development of predictive models and practical criteria useful in the early identification of these high risk users of system of care services.