Webinar: L.A. County Department of Mental Health – Services and Referrals
we also meet the slice user friendly so you can refresh them together today we’re going to present our focus of the permanent mental health our services and our scope you second so the objectives of this training will be to increase in knowledge about the Department of Mental Health to gain awareness of common mental health symptoms across the lifespan and to increase knowledge about how to access mental health services so we’re going to begin just review of the Department of Mental Health we are the largest County based public mental health system in the nation we serve over 250,000 clients annually we run and operate eighty-five directly operated sites so those are DMH clinics basically with DMH county staff we have over 300 co-located eight programs and these co-located programs basically work with other county departments or other systems such as courts an example of this would be we have the MH staff county staff co-located at department of public social services and at all the DCFS offices as well in addition to that we have over a we contract with over a thousand organizations these are your nonprofit organizations such as Pacific Clinic Children’s Bureau etc agencies throughout the county and one of the major reasons for this is also to be have to be able to reach all our clients as it is we are a very large County so we want to make sure that we are accessible to our clients so briefly a little bit about the department in our mission and vision we are in the business of to optimize the hope well-being in life trajectory of our most vulnerable through the access to care and resources that promote not only independent and personal recovery but also connectedness and community reintegration we ambition to create easy access to the right services and the right opportunities at the right time in the right place from the right people our main belief is that people actually do recover from mental health and get or get better and we want to give our clients hope at the end of the tunnel so this is why we we try to help our individuals or clients find hope we want to do it with dignity and we want to make sure they understand that they can recover feel better and be part of society so everybody is fully aware of the scope of Los Angeles County if not however I wanted to show we wanted to show a map of our county we are an every service area one through eight we also ensure that this is part of the reason why we have to contract with some of our providers in order to make sure that we’re everywhere but our services are on Thurs there are ones lancaster palmdale area all the way a service 8 or 8 which long beach okay so who do we serve who is who our clients our population we we serve children all the way from zero from birth all the way to the end of life we make sure that we a lot of our programs have been divided between age groups in order to be able to have better treat our clients because there are special needs for example zero to five children have different needs than maybe older children teenagers are definitely adults we are we also believe that transitional age youth which is a transitional age youth group which is between 16 to 25 years old also have different needs and then our younger youth and also then adults so we make sure that we have some services that are developed and around their needs then we we serve our DOS and older adults the type of services are funding that we take our met account clients can have met account it didn’t funds means for clients that have aren’t unable to play pay for services so they have an ability to pay for services or not insured we’re able to provide services if needed and we also have sliding scale for those that have some form of ability to pay in order for you to understand our system a kind of we wanted to this continuum of care we created this picture for you to understand the best cope of our services most of our clients do not begin our services or seek out services at one point in time some of our clients our services really early on with no symptoms or mild symptom and some of our clients their first initial connection with us is when there are psychiatrically hospitalized so we have a different array of services to meet our clients needs and we’re going to take a little bit of time in this continuum of care flight so it’s kind of explained our best programs that we have available for our community and for you to understand maybe where some of your clients would fit in so the very first one prevention the way we see prevention we have two layers of prevention we have Universal prevention which target the general public or at the whole the idea really here is to educate our entire people our community to understand what is mental health how do people are able to do self-care and take care of themselves what are the steps that you have to take in order to do that also just also understanding and in kindness to other people who are suffering mental illness as well so this is like a universal everybody understanding a little bit about mental health in general mental health services and what’s going on in our community then we have selective prevention which basically targets individuals at risk of developing a mental health issue this not necessarily means that the clients would actually have a mental illness but this would refer to for example working closely for for example we’re co-located in some of our DP SS offices Department of Public social services because we understand that some of the individuals that are attending or receiving those services may be at more risk of developing some or having experiencing some mental health issue so we make ourselves available and ordered in order to be able to be there for that connection some of our examples this is not so much some of our examples of prevention would be partners in suicide prevention or stigma reduction these are trainings that we provide our community we try to talk about how do you how do you handle somebody who’s probably experiencing suicide what do you do where some of the steps that you want to take or stigma reduction how do you understand people who have a mental health issue what are their what are they experiencing how can we be kind and supportive to an individual who is going through something difficult and the next next sections early intervention these programs aim at treating an early diagnostic or individuals with basically mild symptoms some of these programs that we provide here are evidence-based practices that we provide short-term therapy we also have we have we also have the specialized programs for certain experts especially for young children in school maybe they have experienced them some things in the community and then we provide some direct services then the next one outpatient this is something that many people refer to general outpatient many people are more used to receiving outpatient services or when they think of mental health or therapy they really think about somebody going to the clinic and seeing a therapist or a psychiatrist this will be your outpatient services in which you go to the clinic and seek out services some of the examples again our general outpatient for our clients we also have other programs such as recovery resilience and reintegration program this program specifically is a an in-between program from a client who me some outpatient meaning they can attend a clinic for services but mine also needs some in-home services so between a little bit of they get a little bit of in-home services and a little bit of outpatient services we also have other pei programs which is called prevention and early intervention programs there also are provided at the clinic the other section intensive services these services refer to individuals who have these services are provided in the fields there in home services they’re different from all the other programs because they have a 24/7 response component for mental health emergencies they have their own line in which the clients able to contact them 24/7 somebody will be available on the phone and in addition to that if the client is in a real crisis and that somebody from that team will go to the home and assess the person if they need to be hospitalized or it needs some other additional assistance these servant again intensive services are for clients who have a more severe mental health issue we have intensive services both for children for everybody for children teh adult an older adult and we have some specialized programs from them they look very similar but they have some special components depending on the age group one of the programs that you as a home visitor might have been able to refer to a would be able to refer to it’s really called its full service partnerships program FSP which is basically a community-based program that is open for anybody in our community that meets a specific criteria this information about this program can be found on our website the details gives you details exactly of what is the criteria that you want to see in a client before you when you make that referral and the referrals also on our website but this will be a client that will be experienced more severe symptom ology prior to in prior to this area or section outpatient services or early intervention services you don’t really need to do a referral we’ll talk a little bit about how you actually get into the client into those services in a little bit but intensive mental health services you would have to make a referral for those services another example of a state treatment intensive then we have our residential or other services these residential program are some of them are lost facilities for clients they need to be they’re conserved for example also we work in conjunction with our psychiatric hospitals and the last section that we wrote here is our collaborations or collocations we wanted to give you an example of the programs that we actually have they look a little different and they’re a little specialized because we’re working specifically with some of our partner agencies again Department of Children Family Services Department of Public Social Services Department of Health Services Public Health Los Angeles with some school districts we have specialized programs and we’re co-located in some other site so I gave you guys a little bit of information of the array of programs that we have so the types of services that we provide are basic aid therapeutic services we provide psychiatric or medication support case management at support and education groups what difference from each what makes each program unique and different it’s that they provide the same levels this the same type of services but they provide a different level for example and intensive mental health service would probably provide therapy two times a week plus case management once a week and in addition it might provide the extra support of a parent partner or a peer advocate so you would have somebody basically being seen maybe three or four times a week in an intensive mental health outpatient program versus an outpatient program somebody coming to the clinic could still get therapy and case management services and educational support but it might not be every week for example or it would have to be it would be at the clinic but the the the the availability of the services is there so something very important for our department is being culturally humble and this really refers to the fact that we have to start where our clients our culture is multifaceted it’s not necessarily just ethnicity it doesn’t necessarily just refers to somebody’s language it also refers to the experiences that the individual has had often times sometimes trauma therefore what we really aim at at our department is really try to start be culturally humble we refer to peeps are treating each individual and family as an expert of who they are and what end to let us know what are the needs that they have before we prescribe what we think they should think would when we prescribing what we think they should be taking we like to listen to them what are they need what they with a where are they willing to do an example of this would be a client that we really think might be beneficial to do intensive mental health services but does not one to have somebody coming to their home the services might be provider an outpatient setting for some time and with the hopes that building that rapport could allow us later on to be able to serve this client at a much better place maybe at their home we also employ staff with live experience and these are peer advocates and parent partners come our peer advocates and their parent partners are an amazing part of our department because there are individuals who have either gone through our system but within Department mental health in other words they’ve been clients themself or were clients at one point or had a child that was a client at one point the beauty on or the cultural piece of these individuals bring to our department really is for us to learn from them what are the needs of our clients but also they help us connect as a department to our clients and we have I believe we believe that having our peer advocates and parent partners join our team have allowed us to have a better communication and better understanding of a client and really understand the culture of our client of our community we also provide multilingual and we’ll talk we have multilingual capacity we’ve and Department of Mental Health we provide services in the 13 threshold languages we also provide multilingual multicultural services in either through different programs that we have for example we have an API collaborative we have the Latino caucus so we ensure that we provide not only the services that are necessary and the languages are necessary but we also provide training and for our workforce so we can be better trained and understand our our community’s needs see also my name is Geraldine Gomez I’m actually an LCSW over at the prevention Bureau with the Department of Mental Health I’m going to be following up on Rebecca and here we’re gonna really go over what mental health is mental health is comprised of a lot of things there’s a lot of stigma and taboo surrounding mental health and it really has to do with our emotional psychological and social well-being in the Department of Mental Health and especially now with the whole prevention movement we’ve learned something that we all know that everyone does everyone sees mental health differently but there is a connection between body mind and and soul or your emotions and so anything that happens in the – Tech’s the obviously the feelings and can have a physical impact on an on an individual until mental health is comprised of again the emotional psychological and social relationships that a person has it affects how we think feel and act and those are then our experience and mental health all interlinked into how we after how we’re doing on a day to day it determines how we handle stress how we relate to others and make actual choices so when you guys are doing home visitation you’re going to be encountering or you’re encountering children families and we’re assuming that families are comprised of adults and it could be a varying ages and so we’re going to go into some of the basic symptoms that you may see present and some of the children that you see in the families that you visit most commonly in children you can see changes on or irregularities and please have it some children might sleep more or sleep less changes in eating habits you might notice that they have an increased appetite or no appetite at all and these of course are not related to the developmental things that that child is in whether it’s a growth spurt or not these are just typical changes that you might see maybe something happened and as a result the child is no longer eating this after that emotional dysregulation which really means that a child is not able to stop crying for example some of our most intense cases with children you have children that are unable to stop being in the middle of a tantrum for three hours they can cry and cry and cry and so it’s for a prolonged period of time versus your average child that might miss a bit late or will be able to manage their own emotions within a certain period of time and again looking at the well of mental milestone you’re seeing that a child is more sensitive to that they like the tags on article clothing or to sounds or they’re reacting to light or a certain type of noise they don’t do well when there’s too much talking in the room or they’re overreacting or you know react differently when they hear something out in the community so those are all indicators that something is going on that these children are having a response to the environment that something might have happened that may require mental health services for the older kids it would be for poor school performance maybe they’re not getting along with their classmates some might be biters or my height might not be able to get along there might be bullying those are all indicators again that something’s going on within their environment and it’s impacting your school performance and they may be a degreaser to one of our mental health services programs now symptoms common in adult and the symptoms could actually be found in any adult maybe even children from the age of 16 on which we would consider transitional age all the way to the to the very elderly with very slight variations but obviously prolonged changes in move you might have someone that can be extremely sad or down one day or extremely happy very energetic talkative the next day or if you know someone that’s really pretty too tense with their life or a pretty happy-go-lucky person and they start not being themselves you notice a change then that would be something that we would want to look at that you want to pay attention to changes in sleeping an appetite same thing as the children either the person is either sleeping too much or not sleeping at all or they’re waking up in the middle of the night are just having difficulty falling asleep initially any changes in appetite that would look like someone who is either increased in their appetite they’re eating way more than they normally would or they’re not eating at all they’re skipping their meal they don’t have appetite and time is just passing without them really nourishing their body again going back to that mind and body connection any unexplained physical complaints and this is actually very important to notice because and it’s not a symptom that we put in the kids section but it’s really important to note these because a lot of folks from different cultural backgrounds don’t say oh I’m feeling depressed or I’m feeling anxiety they say actually my stomach hurt my head hurt my shoulders hurt I have lower back pain or you know I just don’t feel like getting up I feel really tired very luggage these are all unexplained somatic complaints physical complaint that can be linked to mental health services in this you know again might be a cultural thing might be due to stigma so these are always important to pay attention to we would always want to rule out any medical organic origin however once that’s been cleared out and definitely something we want to take into consideration the next symptom that we look at our changes in mental state or thought and then actually is really interesting because of you have that’s pretty alert pretty oriented when you talk to them but when you go and visit them or you meet them out in the community and they per set very disoriented or they’re confused you know you can always ask what day it is where they are to tell you a little bit about the situation they’re in it’s good to be able to pay attention as to are they able to process the information that you’re asking are they able to provide the information do they know what’s going on in their environment and with them and maybe you know they’re they’re having thoughts where they’re not for their tangent Toller they’re loose or they’re not actually related to the questions that you’re asking then again something very important something something to note you have adults that are seeing or hearing things that other folks might not see or hear you have people that are talking to themselves this happens a lot with the cases of like delirium where you have older folks that you might go see and something medically is going on and that could actually impact their thought process and so they’re talking to themselves or they’re seeing things that aren’t there um so always important to note important to check in with that person see who are you talking to what’s going on just to get a better idea of what’s going on make a note of that and then be able to report that when you’re making that linkage or referral another something the the growing inability to cope with its day-to-day now this could look very different for different folks but it’s really about being able to manage stress Rebecca talks about being able to cope with the things that you do and so with stated they are the folks able to let’s say that they take a bus to the doctor’s appointment or to drop off their kids at school and they’re no longer able to like coordinate their transportation be able to say that able to be or a person that can no longer let’s say manage their schedule keep an agenda that sort of stuff things that they were able to do before or even like if they have five kids in the household or five family members in the household and before they were able to actually have everyone their manager schedules prepare the meals clean the house and all of a sudden you’re noticing that the house is looking the same way they’re screaming at the kids more they’re not taking care of themselves like they were when you first came out those are all indicators that something’s relieved like stressing them out or bothering them or that something’s going on where they’re not able to manage the way that they were managing before the other thing and very very important right now is the presence of suicidal thoughts so so typically come out and this cold oh I want to kill myself today or don’t openly see that they’re having suicidal thoughts but sometimes depending on the rapport that you have established with someone how engaged they are and the program and the services that you’re providing they could have that trust develop where they can share that but if you do notice in terms of suicide that folks are giving away their belongings making statements that they don’t share you know that they’d rather not be here it’s always good to ask and I know that that’s something that we’ll be able to talk about later on but always gauging for suicidal thoughts sometimes there is a high correlation actually one out of every four adult that has depression or is feeling depressed is that the process of suicidal thoughts is there so there is a correlation although not everyone that is the process and that’s so exciting the other thing is substance use if someone is using substances they may use to self-medicate or to deal with emotional pain or whatever is going on in the household it could be something else but we also look for substance use as an indication that something might be going on in the mental health realm so those are things that you can look for insurance of the bills now specifically for pregnant or partum women same thing would apply in terms of changes in mood this is a very interesting period as you all may know because there’s a lot of changes and hormones and lots of mastery so mood changes is very important to note but I think more importantly than anything is the bonding and the attachment difficulties that they’re having with either the newborn or with the other kids in household primarily the newborn because that’s the person that’s going to be the most dependent on the mothering on the new mother also looking for intrusive thought and these women that are having a postpartum symptoms might describe as things that just come into their head they don’t know where it’s coming from it’s just one minute they weren’t thinking about anything and then the minute the next minute it’s there it might be the Oh what happens if I I wonder what would happen if I put the baby in the oven um little things like that that are very concerning but they’re just thoughts that they never thought they would have or that just come in a link that they should have never been a mother or that this kid would be better off with someone else and obviously again going back to that thought about worrying about hurting your baby so now we’re going to talk a little bit about whole reason we’re having this presentation right being able to access care what does that look like our department is huge like Rebecca mentioned earlier and there are many ways that we can access care we’re going to go over three of the basic ways and these are the three most accessible ways of accessing mental health services although one of the ones that we didn’t list would be to basically just walk into one of the clinics but these again are the most easiest ways these are the easiest ways to be able to access care in our department the three that you see up on your computers right now are obviously the DMH website which will look at access line which is a 1-800 number and our service area age navigators and we’ll also talk about that so our website it’s cmh saw La County’s govt and yes and when you log on to the website it’ll have several tabs on there it tells you on our website what our mental health access number is which is the 1-800 number that we’ll be talking about in a little bit but it also tells you the different tab different information that’s provided on there including including public service announcements first folks that have suffered from some form of mental and our actually have regains hope and are on their path to recovery and to well-being so on the website is you note on this slide there is a purple kind of magenta ish box if you go there where it says locate mental health services its denoted by the big red arrow on your screen you can type in a zip code and actually Moche mental health services so if you put in a zip code there it’ll take you to the next page which is a list of different specialty clinics or clinics within that zip code and the list that’s populated is actually a list that is a combination of both are directly operated clinics DMH sites and contract providers which are community-based organizations or private agencies that have the contracts with the image and so they’re also broken down by age group some clinics are very specific in terms of the population that they service so it’s really important to pay attention to that it’ll give you on this site the name of agency to address a phone number and then whether they’re an outpatient facility or inpatient facility which is also very important to note what I see um yes what I see on here is that it doesn’t on this one page that’s populated give you the age group that served however you click on the agency mean it will give you the breakdown of the services and the age groups that are served at that particular site and also the languages that are spoken Rebecca’s gonna speak to you about the access hotline so with access hotline is our 800 phone number many individuals have used it and I’ve attended some of your work group meetings and different questions about how to use the access hotline so I got more information so I can be very prepared for today’s webinar so there’s a phone number you can contact this phone number and then you can give them that again the the zip code or where you’re looking for services and you can let them know specific of what you’re looking for and the person on the other side their answers that call will be able to assist you I asked them how long does it take on average to get the phone call answer and 90% of the time it takes one or two minutes they actually have to they get studied by by médicale actually get audited so it takes about 90% of the time they answer the phone call within one or two minutes so which I think it’s pretty good one of the things about calling access you are able to do several things there you can call to get resources but you also can call them for emergencies mental health emergency non-life-threatening but emergency psychiatric response for example you have a client who’s suicidal or homicidal might not haven’t might have a plan and it might not necessarily have a plan or doesn’t have the it’s expressing that this is something that they want to do and they need help you’re with this person you can contact the access phone number and they will then dispatch what’s caused a Catterick mobile team and they will come to the home or the place where the client is that and access them so this is one of the ways you can use to access hotline the way of using them for resources one of the things that I like they can give the person you as the caller us may be helping the family the home visitor or if the family calls or the client calls and they are willing to give their information they’re actually able to make a referral for them through the phone and what they do is that they tell them what they need they ask a couple questions and then sent through our we call it a assistance tracking a referrals tracking system srts they sent a referral or a request for a referral to an agency that has an opening they send it to them and within 14 days they will then be contacting the client to let them know we got requests for services we are calling you back to make our an appointment or or tell you when to come in so that’s another way of calling access so either again just getting a list of places that you can go to so it can be as easy as that can you give me a couple of names of agencies which you can also do on the website or call your calling them to actually get and be referred to an agency so they will make the referral themselves and then within 14 days that agency will be calling that client and then telling them when to come in so again that doesn’t mean that in 14 days they will be seen in 14 days they within 14 days they would get a call back in order to make an actual appointment so that’s one way and then lastly again we use the active hotline a lot for emergencies one of the things about the access hotline that is very important and you can get a lot more information on our website it’s also it’s a national hotline actually so at a certain time at the end of the day I were in five o’clock not only do they take emergency calls but they’re also able to take the youth calls to do for the county specifically to do services for translation services for languages that are not a certain threshold languages so they have a lot of facets a lot of functions so it is a good number to have for you for your resources now a little bit of our service area navigators again Geraldine said that there were three options and again she reiterates another great option really is to make contact or make become aware or very well acquainted with a couple agencies near your area where you work and then basically just calling them directly and say hey you have an opening that would be another way but the third way that it’s general for everybody it would also include contact our service area navigators Mikayla at the end tomorrow when she sends the slide or the link she will also send some resources and the names and phone numbers or the first era navigators will be included for your purpose for you guys to utilize it so the role of navigator is basically to access services and provide linkage a lot of our client does mean one of the main roles of our service area navigators it’s really is working with a full-service partnership program so our intensive mental health services so in case you find yourself you have a client a mother or or a partner and the family or somebody you’re working with through home visiting that you really think like well this person really has some really high needs again if you go on our website you can tell you a little bit more about what the criteria is but you know basically something’s telling you this is a little bit more you know person’s responding to internal stimuli the person has a serious substance use issue there’s a lot of aggression and maybe the family member or if a family member maybe is your client for example and like Geraldine was saying the client was doing very well but all of a sudden you know you you really are not meeting with this clang anymore her thought processes are weird a little bit afraid this something’s gonna happen and a little bit more than your normal like I’m feeling a little bit sad and you’ve seen some some other symptoms they just you would want to contact the service or navigator and consult with them first of all but then or you even can make that for the SSP referral through them and you can let them know who it is obviously hopefully the family you need to let the person know the crying no unfortunately you have to let them know you know you know we have the service and then you can refer them that way one of the things about service air navigators what they also do they advocate for clients they work and there’s a service area navigator per age group so that’s child pay adult and older adults per service area so technically four per service area and their real focus the besides doing in the intensive SSP services is really to learn their service area get to know their service area and the services in the service area because they also have to provide support through our intensive mental health providers as well so oftentimes for sample we used to work a lot very closely with service punishes for children are our child navigators would know for example you know I research for some of the child that are going through eating disorders for example or they are shelters for families so they would know additional services based on their sir the age group that they’re working with in the service air that they’re working at this is a great resource to have as well because you can consult with them about other things related all to help somebody who has a mental health issue I’m gonna give it back to Geraldine so she can talk to you guys about making the actual link to mental health services I also in terms of linking to care we don’t almost a little crosswalk here for you that you’re seeing on your screen right now for the first question that you definitely want to ask is there a mental health services need and if you go back and and just review the symptoms that we’ve mentioned earlier if there are things that you’re questioning and you feel like this person definitely could use some mental health services then you would go ahead and want to determine whether it requires access and either go to the website call the access hotline the 1-800 by for 77071 or contact your navigator and those numbers again will be provided to your that contact information will be provided to you if you are using our website or calling access you can contact the agency directly and what we try to really always make sure or encourage is that folks that are making linkages actually follow through and contact the agency to find out what the intake times are or if it’s not to walk in what would be better suited for the individual that you’re making the linkage or referral for and the reason for that is we don’t know what the capacity and that person is that you’re working with they’re open to taking the referral the number the information but not really following through with making a call so it’d be best one to make sure that the number is a working number two that you can have a live person and three that you also know the information so that you can one document it and also follow up with the person or be able to call with them while you’re there and then three if you are just providing their information providing them with the appointment feed and time that you’ve created and the contact person at the clinic or just giving them information in general so again this is a very simple path in terms of how to actually link someone to mental health care so with that we and our part of the training session and I’m going to hand it over to dr. Mike Sherman who will present on the medical necessity for mental health treatment obviously in young children and care so here you go dr. Sherman thank you good afternoon everybody one of the things I wanted to talk to you about today is take a look at some of the challenges in referring young children to mental health services and you know simultaneously we know that providing intervention early on in the child’s life is going to be the most cost effective reliable and impactful means towards improving outcomes there’s a ton of research out there that shows that every dollar we invest in early intervention results in seven dollars of benefit to our society at large and some estimates actually show higher fiscal outcomes we know that early intervention improves the cognitive and social-emotional development of young kids specifically those who suffered from neglect abuse or other forms of trauma including multiple replacements being shifted from their biological family to other caregivers in and of itself is traumatic for a very young child separation from a breastfeeding mom certainly would be traumatic for a young child a number of different things that we don’t necessarily consider to be trauma with a capital T child welfare outcomes and placement permanency is significantly improved when we have early intervention from a mental health perspective additionally we know that lifelong mental and physical health issues are addressed through early intervention as well and in fact pretty much all adult outcomes are improved when we intervene earlier rather than waiting until later on to provide intervention that’s often less effective more costly and takes many many more hours of intervention to achieve less effective results ultimately early intervention also results in improved functioning across the lifespan so whether we’re thinking about intervening with a young child for their benefit in the here-and-now or for their but no further improved functioning later on in their life the earlier we intervene the better we’re going to see them function throughout their lifespan so it’s really really pertinent so simultaneously while we know all that to be true we also know that identifying medical necessity is the most nuanced and complex when we’re working with young children we have to deal with the Nexus of a number of different issues happening simultaneously we have their overall development is it typical or are there problems with their development from a developmental perspective from a physical or health perspective and from a socio-emotional perspective do they have challenges that require support from a multitude of different providers including occupational therapy looking at maybe allergies or medical conditions looking at genetic anomalies looking at a number of different factors that contribute to what we often see as very similar symptoms or behavioral issues especially in very young kids so a lot of these things are multi determined and we really have to do our legwork to dig deep enough to see what’s happening additionally we have the impact of all sorts of different things including prenatal exposure to substances prenatal exposure to violence in the community violence in the home we know the toxic stress definitely impact the unborn child and produces quite a lot of outcome differences even when they are detained from the biological family in place in a new setting that might be very safe for them but the prenatal exposure does persist way past that point and we need to really look at that as a risk factor there are many impacts of trauma both on a young child that happened throughout early childhood and they continue on as they traverse different developmental needs throughout their early life and that trauma doesn’t simply go away on its own it gets rican sexualized and reworked every single developmental milestone that they work through and so in supporting families and supporting foster families we have to help them understand that you know while this child faced a lot of adversity before they got to you they are not simply going to be all better because they’re in a safe location now right we have to take meaningful steps to help support them in navigating their developmental course and the best way to do that is by linking them to a mental health service provider that’s going to incorporate not just providing services to the child but working in a dyadic fashion with a child and their primary caregiver together to support the developing relationship we also know that there are a number of systemic barriers that address you know that impact access to care that impact how young kids get into services and those things are fiscal budgetary they have to do with training they have to do with you know some folks who are decision-makers that agencies don’t necessarily have a the most current understanding of early childhood development or trauma or how you know aces and toxic stress impacts on young kids brains and their overall social emotional functioning and so access to care isn’t always the easiest thing especially once we get past our DMH directly operated services and out into the community while there are definitely a lot of very well-trained and providers who are capable of providing these services I think there are still some out there that do need additional support and we’re working on providing so this slide shows the guidelines for LA County for medical mental health services and what I want to highlight for you guys today specifically is that oftentimes for our new clinician especially in the contracted world they’re taught that medical necessity is equivalent to functional impairment and that concept is a very meaningful and that comes from the adult system of care right where if you have an adult client you know what functionally they’re supposed to do they’re supposed to be able to maintain relationships have some sort of meaningful activity but they’re engaged in whether it’s work or hobbies you know manage their hygiene engage in a age-appropriate self-care activities and if they’re not doing those things and that defines their need for mental health services that serves as a functional impairment however if we start to think about a young child especially if we’re talking about a two or three week old or younger or somewhere around that range it’s really hard for providers who don’t have specialized training and quite a bit of it to identify functional impairments even though they do exist and so for those folks what we’ve been really focused on is providing them adequate training to understand that significant risk in and of itself based on history is medical necessity and if you guys look at this slide you understand that the first requirements to have a diagnosis with an allowable included condition of covered by medi-cal now with the DC 0 to 5 which is the diagnostic manual for young children versified we do have a lot of conditions that are included there that are crosswalks over to either the dsm-5 or to the icd-10 which we use for medical billing so that allows number 1 to be taken care of on our n through our providers number 2 is really pertinent because it has three criteria and as I said earlier we primarily teach only the first the first is that you have a significant difficulty in an important area of life functioning which is that functional impairment we spoke about second and third are equally viable and they read that the child has to have a probability of significant deterioration and an important area of life functioning or a probability that the child will not progress developmentally as individually appropriate the key word in both of those is that they have a probability of those things a probability is five percent twenty percent a hundred percent whatever that percentage is there’s a chance that they will not either develop appropriately or that later on they’re going to have a impingement upon their overall functioning so even if the day they have no symptoms but we know their history is severe enough to imply that they’re going to have issues in these things later on we are technically allowed to provide the mental health support you also have to have an expectation that the proposed treatment will somehow improve their functioning and I would hope that none of our providers are providing treatment with no hope of their treatment improving the functioning of their client and that the condition is not solely due to a medical situation and to clarify that if you have a client who has cerebral palsy and that cerebral palsy diagnosis is having some secondary mental health related symptomatology right if the client is depressed about their symptoms they’re feeling anxious about going to school because they’re not sure how they’re going to be received by their peers that client is eligible for the mental health services to address those specific things however if you have a client who has a medical condition diabetes asthma whatever it might be and they have no associated mental health symptoms and it’s the situation that should be addressed by their primary medical physician and not necessarily mental service what we’re doing for versified clients broadly and to increase our capacity is providing training there are a lot of trainings being offered for directly operated mental health programs for our contracted providers and also to our systemic and community partners such as you guys in order to increase the capacity both in terms of service provision and in terms of identifying which clients are capable of accessing the system of care so that we can get them to where they need to be in order to receive services as quickly as possible the other part is that we’re trying to broaden our range of services and so I think I spoke to you guys last year on a very similar topic and we talked about kind of evidence-based programs and what those look like whether it’s from a focused CBT or a parent-child psychotherapy there’s a CPP there’s a number of different acronyms and different programs that are provided through this lens of prevention and early intervention we also have intensive mental health service programs such as ifvs wraparound FSP and all three of those programs have really spent the last year trying to focus on increasing their capacity for servicing younger kids and their families and we also have our prevention and early intervention strategies and I don’t know if somebody’s spoken to you about the stepped care model but the nice thing is is now we have opportunity to provide mental health services that are kind of tight rated appropriately depending on what the presenting issues are for clients who don’t necessarily meet medical necessity but are showing some sub clinical symptoms so it really does allow us to provide intervention at all levels and even earlier than kind of client’s first diagnosis which is typically what Pei services targets for you guys and for a lot of our community members the question of how to best support first try client comes up and I feel like taking a look at some of these factors is really pertinent we always talk about teaming across some systems and within our County being as large as we are we have a history of functioning in a very siloed manner right kind of DCFS does their thing dnh does their thing public you know public health does theirs our home visitors kind of have had to traverse those large systems and past to gain access to information to gain access to care and our hope is that we’re doing a better job of teaming with one another and also teaming with you guys to allow you entry into our system books in terms of receiving information and sending clients up in both directions definitely advocacy is a big one and I think for those folks who have an interest in advocating on behalf of their clients you know I encourage you guys to continue to do that don’t just make the referral and hand somebody a piece of paper with a phone number on it so really follow up and manage the transition you know advocate for a client to be seen if you feel like they genuinely need to be because at times you know providers will respond differently to a phone call from somebody who has lived experience with a client than they would to just a simple intake form that has a little bit of information about the client background so definitely advocate as much as you can the other pieces that my encouragement to all of our staff that I’ve trained and that I work with is to begin with an assumption that young children especially those that are engaged in services with child protective or the Department of Child and Family Services can benefit from intervention right historically our assumption is well this client doesn’t need medical necessity and I have to figure out why they do my suggestion is start with an understanding that our youngest and most vulnerable kids who have a history of abuse and neglect to have that has resulted in them being removed from their parents and placed sometimes in many many different settings start with the assumption that they are at risk and they do need medical necessity and start to think about maybe reasons why they might not right start to identify does the shall have an exorbitant amount of resiliency factors do they have excellent care and support have the parents done everything they need to do in order to reunify with this child are they having successful visitation as a child supported in navigating this experience and if so then maybe we might be able to make a case for why they don’t need medical necessity but otherwise the basic assumption should be that they can benefit from mental health services and then the other part is you know this work is hard when we’re working with traumatized young kid we need to really understand that it’s draining on us it’s draining on the systems involved and we have to acknowledge both our personal barriers to providing the ultimate care that we’re able to provide as well systemic barriers and actively work to resolve both what’s happening for us and kind of managing our own burnout as well as working to advocate that the system become more responsive to the needs of our clients so with that said I want to kind of put it back to Michaela and see if there are any questions that folks have that they would like to send our way thank you so much this has been super informative so we do have some questions coming in and I’ll go ahead and start from the top and feel free to keep adding questions into the chat box just for those of you that weren’t here at the beginning everyone is muted and will stay muted because when we have this number of people there tends to be a lot of background noise so if you have questions please type them into the chat box and so the first one was for the FSP program for intensive services are the services only for the child or only for the mom or does the program support the dyad so in general only 4:05 usually the pyramid include the diet for over four children or above six six and older it would be specifically for that child and also for adults however if you have to focus on who the focus client is for example if the mother has a severe mental health issue then at that moment you would really refer the mom to the mental health services so it will be mom receiving the FFC services for her to get better so now a child I would refer to zero to five FSP specifically would be somebody kind of going back to what Mike was saying has a history of possible maybe being detained from family has had a lot of other issues or its exhibiting some serious symptoms for example at preschool or early care or childcare fighting a lot of constant crying for like hours at a time there’s something going on so those some those are symptoms that you can easily see I think but there’s more difficult symptoms that you can still refer to us for example would be maybe a mom that is having some some post summer up postpartum depression it seems like it’s really affecting the attachment again like Mike said you’re seeing that maybe the child’s not really developing the weight the child should be for example the child 3 months is not really gaining weight you’re seeing them on symptoms like a severe but really this is something like a change for the mom mom was doing well meeting when she was pregnant he would be referring specifically noting that that they are some symptoms with the mom this is really affecting the child a child’s not really seems to be developing West’s child should be so that would be like a zero to five when you look at the FSC referral it will be a zero to five section and then you will let right there indicate the mom has or the parent has some mental health issues going on or one of them being preschool not doing well in pictures so that would be like an example the child is you would refer so through chil FSP they can provide some services for the for the parent they can provide therapy for the parent through what’s called ffs ffs’ yes okay Thank You Rebecca so the next question I’m I’m not entirely clear on what the question is but it says I have families that are required to get mental health services by Children’s Court for parents so I think they’re asking about if there are any services for court-mandated mental health services that DMH offers so the challenge would be to kind of report on you know court often mandate services for parents who don’t actually have any symptoms they just want them to seek support and counseling to address relational issues or things along those lines so I think if the parent meets again medical necessity criteria that would be why we would take the client and provide the mental health services the court order in and of itself is not a make a requirement for us to providing services it’s a requirement of the individual seek out services somewhere the challenge is again if the parent meets medical necessity there are certainly many adult programs where they can and will be seen for mental health support and services whether the you know there’s no way to know that until they’re assessed and evaluated and so the general step would be to refer them and then follow up to see if that you know their case was open if they were accepted for treatment or not and typically DCFS actually has a section their back-end work very stocked to provide information in terms of agencies they can go and receive that mandated time treatment from typically our clinics do not provide court-ordered treatment because the courts specifically like Mike said specify the type of treatment that they want and they require the annex number of reports that our clinics will not provide and so again if mom needs medical necessity you’re almost always you’re always welcome to access the website provides the referral list and have them contact each agency but it’s working from an adult world unless they need some sort of need for services the specific type of services would be very limited okay thank you so then we have a few different questions about the access line so I’ll try and sort of combine them so you can address them all at once the first question is when we call the access line or p.m. RT for a suicidal claim do we need to assess insurance status or is that service open to clients who are privately insured you know I thought buying actually for the psychiatric mobile response team takes any and all calls regardless of medical insurance state status when a PRT call it taken we go out and evaluate if someone is in a danger to themselves to someone else are gravely disabled so will dispatch regardless of insurance status that is not something that the person that calling access needs to learn if they do learn it and that’s great it would help us along the way but if they don’t send that’s also okay the one thing that’s really important to note though when there is AP MRT request made that the requester the person meant calling in for the service or for the evaluation be present and lay eyes on the individual after making the call for because of their not available and on site when PRT gets dispatched the team will not dispatch okay Thank You Geraldine so the next questions about access are about sort of what happens once access is called so one question is about how a home visitor might prepare their clients for what to expect when using that service and then the other question is about whether or not the staff who respond to a call on the access line have been trained in trauma-informed approaches okay so the first question of what to expect so when you call them you will get you will be asked actually if it’s like an emergency or will be for something else because they have to reroute you so when you’re asking for something else meaning your one resources once you get somebody on the phone they will be talking to you about what they’re feeling you don’t really have to have that much preparation you just need to let them what you’re seeking because they’re not going to be necessarily doing an assessment of what you do only with an emergency now if you’re thinking that if it’s an emergency and you need a peer Marty that’s a little bit more different because you have to see what’s going on who do we need to send exactly for example sometimes it’s not even PMRC sometimes it’s access calling 9-1-1 for example but for just getting a general referral they’re going to ask questions along the lines okay what’s going on what is it for you is it for somebody else if it’s for the mom for the child for example usually you know they speak to the mom and then that’s when they can ask them I mentioned it in which that if they are willing to give their information some families are not and they just rather get a list of referrals so it really depends on them but some of them are willing to say I want to be referred somewhere so they make a referral through our systems our systems tracking referral system and which is called srts and again they make they make a referral to an agency and then within 14 days that agencies up you have the family has to be giving their phone number and address and then within 14 days they contact that MA person and let them know okay we got your referral where this is the peak that we have available for you to come in so that’s what happened so those are know it so the other question regarding being trauma-informed so that would be more for like the emergency people who are going to have like for example this is an emergency and they would in general most of our staff and DMH or anybody we offer actually have all been trained in trauma-informed care some of us have received more training and others but it’s specifically for access blind they are trained constant and how to receive how to engage clients as well because even though it might not be an emergency or they might not click that is an emergency it may become an emergency within a minute so they are fully trained to repeat those type of call okay um two more related to part-1 is approximately how many responders are there per region or per spa and then the other one is I know you just said it it generally takes about two minutes for a call to be answered but the question is how long does it take for P MRT to respond I think that means in emergency situations to actually arrive at the location of the emergency psychiatric mobile response team is actually a service that’s available during the day during regular business hours and for that we have various teams that are available broken up obviously by service areas and depending on the number of teams and the nature of the calls there is no sign you know logic logic model or equation that will give us an exact number of or exact time measurement of how long it would take to respond that’s not something we can really state after hours which means after five o’clock to 2:00 in the morning those are folks that are volunteering or there for shift after regular business hours so folks that work during the day so it depends on the availability of the number of teams per service area and because we cover countywide from two to eight the number of teams available to respond to whatever ex-member of calls there are so if there’s no fine equation solve one has their own team mike is asking about how one solve one service area one the amylose Valley because of the size of amylose Valley we have our own designated services the third that are so p.m. RT bound but their teams particularly provide services only for animals Sally so first off 2 through 8 service areas 2 through 8 it depends on the number of teams that are logged on for example on a given search what is today today is Wednesday so for today in one service area service area 5 per se we might have three separate teams signed up for service area 5 and only one team signed up for service area 8 and if we don’t have any other team signed up across the different service area than most 14 have to take the prioritize calls in the community based on whatever you know whatever given to them and how they dispassion and and there aren’t any specific factors that will give us an equation and I’m sorry I don’t have a straight answer for that but it just it depends and this is Rebecca just to add I think the department’s also aware of the need to have more teams than one of the things is that by law and to protect our clients you have to have a specific training to be able to put people on a hold so it’s not just you being licensed or you’re just being and you know having some experience there’s actual and expectation of doing extra trainings for it so it’s a little bit more specialized and that has to do with the fact that we want to make sure we protect our clients right thank you both that was really helpful so another question is under what grounds should be raising a flag to send zero to five children to therapy so I wonder if maybe you want to put back up the signs and symptoms of mental health issues in young children and while you do that go ahead I was gonna say I think that’s a great question for dr. Schurman okay um so again I think you know it’s always a good idea if you have a child that has suffered abuse or neglect that is involved in DCFS and has had exposure to prenatal substance abuse exposure to significant trauma exposure to domestic violence you know all of those scenarios in my mind warrant a referral for an assessment evaluation at that point it’s no longer is on the home visitor to determine whether that child meets criteria for services or not that then is the determination by the treating provider again I think the access to care issue is a significant one and it’s when we’re trying to address but the challenge is that you know the eyes can’t see what the mind doesn’t know and we have a number of providers out there who although they are trained in intervention for birth to five I think that the focus primarily is on kids who exhibit externalizing symptoms that is they’re doing too much of something that gets in a way of their preschool functioning that gets in the way of their home functioning they’re crying too much they’re biting too much they’re hitting too much they’re you know out of control and running around too much and those kids typically get into services where my personal concern lies and what we’re trying to address is the kids who show internalizing symptoms the ones that are anxious are depressed or showing less engagement that we would typically want to see and what we notice traditionally is what happens with those kids is they get into the foster care system and foster parents say well this little guy an angel he’s perfect he doesn’t bother me he doesn’t cry much he doesn’t ask for much he’s great and they’re not attacks on their time they don’t get in the way of their other daily activities for the foster family and oftentimes for me that actually raises a larger red flag because if you think about what that child has just been through right with the detention with the trauma that they’ve suffered they should be crying they should be distressed they should be distraught and if they’re not that’s a significant concern and a big red flag for me and I would certainly refer those kids as well so kind of think about what you know how you would feel woken up at 3:00 a.m. pulled out of your home you know missing all of the things you’re typically used to and didn’t have words to share your discomfort didn’t have a great understanding of what’s going on and how disorienting that must feel and how traumatizing that must feel and with that in mind think about placing yourself in the shoes of these little ones and what they’re going through and that’s where a lot of our training efforts are focused and a lot of our advocacy efforts are focused at these kids who later on are going to present with very significant symptoms more likely than not and we know that children detained by DCFS 80% of them are at risk for developmental delay we know that quite a few of them are at risk for mental health concerns later on in their lives and the earlier we intervene the better the outcomes are going to be so it’s in all of our interests to provide that intervention and I would lean on referring kids more often than not personally thank you this is really oh sorry go ahead I just wanted to add a little bit to that because I know many of the home visitors were saying that maybe they’re not being detained by DCFS but one of the things to stir iterate a lot of times they’re aware that there has been domestic violence that the father or the partner is no longer in the home so those are again distributer if you have that type of information you should be referring memnos you don’t even have to wait to see symptoms because just the fact that they are so young and they were experiencing this drama is obviously symptom enough to be referred thank you I think those are really good reminders the next question is what referrals do you provide for undocumented individuals so when it comes to services mental services we don’t we don’t ask people if there are documents or not we go based on if they have ability to pay that’s the reason why I when we the slide that we talked about who is our population I will go back to it for you guys to see it a little bit but we have people who have médicale which obviously you would have to have some form of documentation in order for you to obtain that and then you have indented funds and sliding scale so indigent funds would be for clients who either undocumented or unable to be insured or uninsured or at a very low income that might not necessarily have to pay anything but they will be under indigent so it when it comes down to what services are our programs all our programs have some form take some indigent funds great thank you the next question is is there home visitation available for postpartum women who meet medical necessity but who do not meet criteria for FSP so one again going to one of the programs that is between programs it would be under outpatient or triple our program or recovery resilience and reintegration program it’s a marriage between our general outpatient and in-home services this program basically it many people used to be called FCC s it just it was really the step-down for FFP or Mesa or you can consider it the program that is between general outpatient and intensive mental health services in other words they don’t really meet the criteria for intensive services but they need in-home services in fact this program when it was called a CCS was actually began with old elderly with our older adults program because many of our clients due to their physical advanced age and some being fragile they wouldn’t be able to come to the clinic so this was one of the programs that was actually to target them and eventually I started opening up to all the age groups so it is one of those programs that is available that will be able to provide in-home services but not but you don’t have to be intensive one of the things though about Triple R which because it is to have in mind though is that you don’t have all the services that intensive do but you do have a therapy you can have the case management and some of the problems also have parent partners or peer advocates and also eventually though the plan is that once the person is a little bit more stable they will be coming into the office right now the way Triple R is looking is one of those programs in which some of the clients might start being seen in home and then as they get better they get to be seen in the clinic and the good thing is that we don’t change the therapist so like that it could be a continuum of care okay great I’m just okay I’m sorry or a triple are though unlike FSP FFP everything is at home the intensive services source so even the the intake the the actual assessment would be done at that home or at the client children’s school or cetera but with Triple R the intake is going to have to be done at the office however after the intake if the family really requires services at home then the services can continue there now just I just wanted to share that with you okay thank you so the last couple questions are about relationship building on a regional level with the DMH offices in the area of the home visiting programs and in particular there was a question about how to try and create a Memorandum of Understanding for a service partnership with local DMH offices so i know as you mentioned i’m going to send out some materials which include the contact information for the mental health navigators in each region is that the best way to start forming a relationship or is there another route that you would recommend so you know if depends on which programs were talking about but I think when you’re having to deal with the child welfare sector which I’m kind of a little bit more comfortable talking about I think that you know I would certainly agree that relationships are really key to functionally assisting our clients the better we’re able to develop and maintain those relationships the more optimal our services are going to be across the range of both of our networks of care in terms of mo use and such you know each service area have their own program managers and district Chiefs for pretty much every program you can think of within DMH and so I would attempt to attend the service area meetings and start developing those relationships and have those discussions with the service area folks but to be honest I don’t think any of us in this room currently are in a position to respond to requests for memorandums of understanding or any such document okay great so we are actually pretty much right at time I want to thank our speakers for all of that information and for answering our questions that was incredibly helpful and thank you to the folks on the line for asking all those great questions just a reminder that the webinar has been recorded so we’ll send out a link to the recording as well as copies of the materials and some additional resources that the speaker is prepared for you so thank you all again and thank you especially to Geraldine Gomez and Rebecca Hurtado and Mike Sherman for your time and all of that information and with that I think we will close there and enjoy the rest of your afternoons thank you so much thank you
This webinar was presented July 18, 2018, by the Los Angeles County Perinatal and Early Childhood Home Visitation Consortium (HomeVisitingLA.org) in partnership with the L.A. County Department of Mental Health.
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❤❤❤thank you❤❤❤