Crime lessens with better care

[Editor's Note:This story is the second of a two-part series on improving care of high-risk youth enrolled in Medicaid. This month, we examine the impact of improved quality on subsequent contacts with the juvenile justice system. Last month, we reported on new approaches being utilized to improve care of this population.]

Youth experiencing serious emotional disturbance make up about 15% to 20% of the population in juvenile justice facilities, according to Laurel Stine, director of federal relations at the Bazelon Center for Mental Health Law in Washington, DC.

"This rate is up to 10 times higher than their representation in the community," says Ms. Stine. "Between 60% and 80% of youth involved with the juvenile justice system meet the criteria for at least one psychiatric diagnosis. Of this group, approximately 80% meet the criteria for two or more mental health or substance abuse disorders."

CEO Knute Rotto, director of the Dawn Project, an Indianapolis-based organization that works with youth and families served by multiple public systems, including Medicaid, points to data from 2008, the most recent year available. This indicates that 83% of youth were successful in staying out of the system, including juvenile justice, after leaving the program.

In addition, 94% of youth referred to the Dawn Project by the Marion Superior Court Juvenile Division did not engage in delinquent behaviors at the time of their most recent assessment, compared to only 50% at intake. "The Dawn Project has increased collaboration and coordination among child-serving systems. This has led to improved outcomes for youth and their families," says Mr. Rotto.

Strategy is cost-effective

Stephen A. Gilbertson, clinical program coordinator for Wraparound Milwaukee in Wisconsin, says there is no question that improving care of youth with serious emotional disturbance not only results in better medical outcomes, but it also reduces crime. "It is incredibly cost-effective," he says.

He points to a study dating back to 2001, which found that only 21% of 490 kids referred to the Wraparound Milwaukee program had no prior arrests or referrals to the juvenile justice system. Many of the youth had been found delinquent of serious and violent crimes prior to their Wraparound Milwaukee enrollment.

Over a five-year period, 60% of youth had no additional arrests or referrals while in the Wraparound Milwaukee program. During a one year post-enrollment period, 68% had no new arrests or juvenile justice referrals. Mr. Gilbertson says that these numbers have held steady over the years.

"We regularly track juvenile justice outcomes through our collaborative relationship with probation and the courts. Our findings have been consistent, if not somewhat improved, over the years," says Mr. Gilbertson. "Thankfully, we are finding that of those youth who have subsequent arrests, these tend to be non-violent misdemeanors vs. violent offenses resulting in incarceration."

Utilization of less restrictive care has resulted in better outcomes at a lower cost than the prior system, "which was heavily reliant upon long stays in residential treatment, repeated psychiatric hospitalization, and even incarceration," says Mr. Gilbertson.

Stringent authorization process

One thing that makes Wraparound Milwaukee unique is its status as a Medicaid behavioral health HMO. "Kids that are at risk for residential treatment or very high levels of care are enrolled in our managed care approach. We're at risk for the cost of their care, just like any traditional HMO," says Mr. Gilbertson. "Managing the care of this generally very high-cost, complex-needs population has proven to be very cost-effective."

Mr. Gilbertson credits Wraparound Milwaukee's success to several different approaches, including a prior authorization process done at the management level. In order for a child to enter into residential treatment, they need to be prior-authorized by a clinician within the administrative team.

"Any subsequent authorization has to go through a pretty extensive review process," Mr. Gilbertson says. "We are not turning over the decision of whether kids are ready to leave to the provider of the residential care. It's not completely in their hands to decide they need another three months of treatment."

Decision is collaborative

Instead, the decision is a collaborative process focused on outcomes. In order for that to work, though, there must be viable community-based alternatives to residential care.

"We've spent many years developing and enhancing the community-based services that are necessary," says Mr. Gilbertson. "In order to work effectively with these kids and their families, we have a real broad cadre of clinical and adjunctive services available in the community."

That includes crisis workers who intervene when a family is in crisis. A mobile urgent treatment team is available 24 hours a day, 7 days a week, staffed by clinicians who respond if there is an emergency or crisis that a family needs help with.

"Rather than the police necessarily having to be called, this clinical team can respond. This oftentimes diverts kids from having to be hospitalized, which is a huge savings," says Mr. Gilbertson. While the mobile urgent treatment team once served only youth enrolled in Medicaid, it now serves the entire community. It also has a contract with the public school system to respond to crises within the schools.

"So it's hitting all those situations where things can go wrong and can result in decisions being made that are costly, and also are not really in the best interest of the kid as far as outcomes are concerned," says Mr. Gilbertson.

This past year, a program called REACH was started within Wraparound Milwaukee, which allows parents to self-refer when they are having difficulties with their kids. The program is in partnership with the Safe Schools Initiative, a federally funded program.

Whereas the traditional Wraparound Milwaukee program was reserved for youth already in the child welfare or juvenile justice system, the REACH program identifies them before that point. "It is available to any child who meets the 'serious emotional disturbance' and other Medicaid criteria," says Mr. Gilbertson. "By virtue of that, we are identifying vulnerable young people earlier."

The goal is to prevent more complicated youth and family problems that can result in out-of-home placements. "We are allowing them access to essentially the same mix of clinical and support services as are available within the traditional Wraparound Milwaukee program, although we obviously can't place REACH kids in foster or group homes or residential treatment without formal court involvement," says Mr. Gilbertson.

In both traditional Wraparound Milwaukee and REACH, a lot of work is done on the front end by care coordinators who visit the kids and families in their homes. The emphasis is on making things convenient. Assistance is provided for what families identify as their current concerns, as opposed to "expert-driven" care.

"There is a real emphasis on empowering families to have access to what they need in the community," says Mr. Gilbertson. "If they have a child who is chronically vulnerable, they need to know where to go to get help when they need it."

Contact Mr. Gilbertson at (414) 257-7209 or and Ms. Stine at (202) 320-5100 or