Past Projects

Brief Summary:

The Safety-Net project was intended to disrupt disparities in mental health treatment access for children at risk for childhood trauma, also known as ACEs, and/or serious emotional disturbance (SED). "Safety Net" used mobile clinical and family support teams to improve mental health outcomes. This clinical innovation was nested in an integrated system-of-care and was piloted
for children ages 3–18 with SED who received primary care through Cambridge Health Alliance.

Detailed Description:

"Safety Net" used mobile clinical and family support teams to improve mental health outcomes. This clinical innovation, nested in an integrated system-of-care, was piloted for children ages 3–18 with SED who received primary care through Cambridge Health Alliance. Massachusetts had the highest rate of child abuse and neglect in the U.S. during 2016 (DHHS, 2017). Approximately 25% of these children lived below the federal poverty level (American Community Survey, 2011–2013). The "gateway" cities targeted in Metro-Boston, Malden and Everett, had 2–3 times the rate of foreign-born residents compared to the rest of Massachusetts (43% vs. 15%) and twice the statewide rate of children whose parental language was not English
(54% vs. 22.3%). Together, SED and ACEs placed children at much higher risk for adverse health and mental health outcomes in childhood and beyond.

CHA's Children's Health Initiative (CHI) leadership combined evidence-based interventions from its earlier MHSPY program, including family support, care management, and shared goals, with new strategies such as interdisciplinary child mental health evaluation teams, all within primary care. Clinical expertise was combined with peer-to-peer parent/guardian support for
trauma-informed care delivery to both parent and child. All aspects of the care continuum were provided in a culturally and linguistically competent manner, with child- and family-driven care planning.

Overall, the program was sited in two cities and was supported by a larger, specialized system of care involving state and local child-serving agencies, schools, and community resources. The study team served 171 children and families in total, at approximately 70 children per year. The goals of the program included:

1. Promoting earlier recognition of child mental health needs;
2. Using a family-driven assessment approach to offset disparities in treatment engagement
   and outcomes; and
3. Facilitating state, local, and care-planning team coordination and collaboration using system-of-care principles.

The objectives included:

1. Assessing the presence of SED through standardized measures of clinical functioning, including CGAS and CAFAS;
2. Screening for adverse childhood experiences (ACEs) using a modified ACE-Q tool;
3. Increasing access to child mental health evaluation and treatment using pre-post measures of patterns of service use for study participants and assessment of patterns of care for a propensity-score weighted comparison group;
4. Improving family care experience, as measured by baseline and follow-up Family Professional Partnership Scale assessments; and Improving clinical functioning, as measured by baseline and follow-up CGAS and CAFAS assessments.
5. Safety-Net's goals aligned with CHA's goals within its Accountable Care Organization contract with MassHealth, thus offering a chance to measure and evaluate outcomes for a customized system-of-care for some of the state's most vulnerable populations.

SAMHSA grant: "Enhancing Systems of Care"

CHA's Children's Health Initiative (CHI), under the direction of PI, Dr. Katherine E. Grimes, was awarded a 4-year system-of-care grant from the federal Substance Abuse and Mental Health Services Agency. E-SOC ran from 9/30/16-9/30/20.

• Pilot Experience: E-SOC built on 12 years of success with the Massachusetts MHSPY model for community-based, interagency strategies related to improving child outcomes, leveraging social determinants of health; as well as recent Windsor St. Collaborative Practice Model, CHA's pilot for motivations in integrated care delivery within Pediatrics.
• Population: Children, 3 – 18 years old, with PCP's in CHA, who were referred from primary care having either screened positive for ‘serious emotional disturbance' or where the PCP noted specific predisposing risk factors.
• Sites: Primary Care clinic ‘hub' sites Windsor and Broadway

Specific Goals of CHA's E-SOC Project:

• To improve access to child mental health and substance abuse (MH/SA) care – expand primary care screening and increase availability of timely evaluation and treatment, with a special focus on recognition and response to childhood trauma.
• To improve youth and family engagement in MH/SA care – including greater communication between parents/caregivers and clinicians, and processes for outreach and tracking of referrals, as well as reduction of barriers such as language, culture, affordability and distance.
• To improve clinical functioning – as reported by mental health providers, families, as well as self-report by youth with mental health needs.
• To enhance integrated care delivery – including more real-time opportunities for collaboration; direct and indirect ways to "share care" between Primary Care Pediatrics, Family Medicine and Child Mental Health, with resulting increases in individualized treatment plans and adherence.
• To improve community-linkages; with parent advocacy groups (PPAL, NAMI), school systems, and child-serving agencies, such as child welfare (DCF), and mental health (DMH), as well as with Cambridge and Somerville Police, and specialty substance abuse (IHR)

The E-SOC child integrated care teams relied on the three defining activities of the Collaborative Practice Model: co-location, coordination and collaboration. However, recognizing that each hub will have its own culture, we worked closely with clinic leadership and provider teams to identify which characteristics of our Windsor St. pilot approach were readily transportable, what needed adapting, and any new elements that were likely to increase effectiveness and further improve outcomes.

Throughout the E-SOC implementation process and evaluation, we maintained our focus on the overarching hypothesis, which is that earlier, and more comprehensive, integration of care for children will improve health care quality and expense outcomes throughout the lifespan.

The Massachusetts MHSPY Program

From 1998 to 2009, the Children's Health Initiative provided the research arm of a longitudinal study involving family driven community based intensive clinical intervention project called the Massachusetts Mental Health Services Program for Youth (MHSPY). Founded by Dr. Katherine E. Grimes, MHSPY is a nationally and internationally recognized model for integrated systems of care on behalf of children with serious emotional disturbance.

Initially sponsored as a two year pilot by the Robert Wood Johnson Foundation, the MHSPY program went on to become a twelve year demonstration project for innovations in:

• Clinical delivery of children's health services
• Child mental health policy and governance structures, and
• Health care financing​

The MHSPY model is intended to maintain youth with severe functional impairment in the community via delivery of integrated primary care, mental health, substance abuse, and social services. The MHSPY program served children and teens in the towns of Cambridge, Somerville, Malden, Medford, and Everett who were referred by child serving agencies due to difficulties at home, school, and/or in the community.

Key features were coordinated, individualized, family-focused and community-based care delivered to youth and families so that children could live at home, stay in school, and continue to grow and learn. The MHSPY shared governance model included the State Departments of Medicaid, Children and Families, Youth Services (juvenile justice), Mental Health, and Education.

Outcomes derived from repeated measures of clinical functioning, service utilization, cost, and care experience from baseline to discharge were monitored and analyzed for over ten years by the CHI, with guidance from national experts on the CHI Advisory Group.​

The MHSPY Process

MHSPY was designed to provide support to youth and families by surrounding them with resources based in their own communities. Our hypothesis was that the best way to support vulnerable children and adolescents was to identify an individualized group of formal and informal supports (i.e. caregivers, teachers, and doctors). These child and family resources were invited to participate in the child's Care Planning Team.

The Care Planning Team met regularly to help identify the strengths and needs of the child, to set goals, and to implement and monitor customized interventions. All of the MHSPY participating agencies, including the Department of Children and Families (DCF), the Department of Mental Health (DMH), the Department of Youth Services (DYS), the Department of Education (DOE), and MassHealth contributed to the blended funding that was used to address the child's needs. Each Care Planning Team was guided by a MHSPY Care Manager; Care Managers were experienced mental health professionals who also served as key contacts for community partners and MHSPY stakeholders.

MHSPY Outcomes

The MHSPY clinical intervention combined mental health, pediatric and substance abuse services to maintain Medicaid youth with serious emotional disturbance (SED) in their homes and communities. The MHSPY study monitored results in four discrete outcome domains for children with serious emotional disturbance who were considered at-risk of out-of-home placement: (1) functional status, (2) utilization, (3) cost, and (4) care experience.

The study employed a longitudinal, multi-wave process using standardized measures of clinical functioning, service utilization, cost and satisfaction for children ages 3 through 19. Multiple standardized measures were administered to assess the overall level of functioning of the target population and identify the presence of change in mental health status at intake and every six months while the participant was enrolled in the program. These measures included the Child and Adolescent Functional Assessment Scale (CAFAS), Child Global Assessment Scale (CGAS), Child Patient Assessment Tool (PAT), ChildBehavior Checklist (CBCL), Youth Self Report (YSR), Teacher Report Form (TRF), Family Centered Behavior Scale (FCBS), as well as Family, Youth and Agency Satisfaction Surveys. Service utilization and expense data was also maintained on all medical services, including mental health and substance abuse, pharmacy, emergency room use, surgery, medication, and labs for all enrolled MHSPY youth.

Through MHSPY, these children received specialized mental health treatment (including psychiatric hospitalization and medication), comprehensive medical care (MassHealth Standard benefit, which included ER, inpatient, outpatient, etc.) and a variety of individualized, non-traditional services (such as family support) outside the Medicaid benefit. Together these resources enabled MHSPY graduates to attend school and live in their communities. Results from MHSPY's final Contract Status Meeting in 2008 reported that:

• 88% of overall program days for youth were spent at home
• Hospitalization rates during 12 mos. of enrollment were reduced 70% compared to the 12 mos. prior to enrollment; Residential Treatment settings use declined for the same period by 81%
• Total medical expense (including hospital, ER, etc.) were 11% lower than those for the Medicaid Standard benefit reference group, 47% lower than Commercial, and 82% lower than for Medicaid Disabled
• In addition to using fewer hospital days and costing less, MHSPY enrollees and their families were engaged in their care and showed significant clinical improvement. Clinical results and care experience findings across sites include:
• Average overall improvement at 18 months in CAFAS scores was 22 pts., indicating clinical change
• CAFAS Thinking score at 18 months improved 51%; Community Risk improved 31%
• Lethality score at 24 months improved 29%; CGAS improved 17% at 24 months
• Family Centered Behavior Scale indicated 96% of families felt their MHSPY Care Manager “helps them expect good things in the future for themselves and their children."
• Parents reported being “Satisfied" or “Very Satisfied" 86% of the time with the help they received
• The drop-out rate for MHSPY was only 2% , despite enormous barriers to engagement

These results have been reliable across instruments and reproducible over time. They represent the combined efforts of the families and youth themselves, the dedicated MHSPY clinical staff, the inter-agency Care Planning Teams. These creative and resourceful teams were invaluable, and as were all the system partners who were willing to spend the “time it takes" (average length of enrollment was 20 months) to help each child and family practice pathways to health. Given the state's challenge to improve identification and care for youth with serious emotional disturbance, the MHSPY model is a tested approach for providing maximal clinical cost-effectiveness within a strength-based, family driven system of care.

External Evaluations

Stroul BA, Pires SA, Boyce S, Krivelyova A, Walrath C. Return on Investment in Systems of Care for Children With Behavioral Health Challenges. Georgetown University Center for Child and Human Development, National Technical Assistance Center for Children's Mental Health. April 2014.

Rowland MD, Woolston J, Adnopoz J. Intensive home-based family preservation approaches, including multisystemic therapy.  In Martin, Volkmar, & Lewis (Eds.) Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th Edition. 2007;878-887.

Stroul BA. Integrating mental health services into primary care settings: Summary of special forum. Prepared for 2006 Georgetown University Training Institutes, Management and Training Innovations. 2007.

Israel N. Improving Children's Mental Health Case Management Services in Medicaid: A Sub-Report to the Florida Agency for Healthcare Administration. Department of Child and Family Studies Louis de la Parte Florida Mental Health Institute University of South Florida. 2006.

Friedman RM. Improving the effectiveness of Medicaid funded children's mental health services. Tampa, FL: Louis de la Parte Florida Mental Health Institute. University of South Florida. 2006.

Remschmidt H, Belfer M. Mental health care for children and adolescents worldwide: A review. World Psychiatry. 2005;4(3):147-153.

Hepburn K, McCarthy J. Making interagency initiatives work for children and families in the child welfare system. Promising approaches for behavioral health services to children and adolescents and their families in managed care systems, 3. Washington, DC: National Technical Assistance Center for Children's Mental Health, Georgetown University Center for Child and Human Development. 2003;51-63.

Pires SA. Managed care design and financing. Promising approaches for behavioral health services to children and adolescents and their families in managed care systems, 1. Tampa, FL: Research and Training Center for Children's Mental Health, Louis de la Parte Florida Mental Health Institute, University of South Florida. 2002;36-41.

Sharfstein J. Unhealthy partnership: How Massachusetts and its managed care contractor shortchange troubled children. Public Citizen Health Research Group. 2001;17(2):1-6.

Zimmerman B, Schwalberg R, Botsko C, Gallagher J. Borzsak D. Mental and Physical Health: Barriers to and Strategies for Improved Integration, Volume 2: Case Study Reports. Prepared for Maternal and Child Health Bureau, U.S. Department of Health and Human Services, Health Resources and Services Administration. 2001.