Dauphin County MH/MR Program
Family-Based Mental Health Services
Chart Review Summary
In 2008 Dauphin County MH/MR Program developed a plan to monitor and manage the County’s use of
Residential Treatment Facilities (RTF). The overall goal of this plan is to reduce the census of Dauphin
County children/adolescents in RTF to 50 at any given time. This represents a 50% decrease in the
average daily census of Dauphin County residents in RTFs. The comprehensive plan includes strategies
to monitor length of stays for individuals in RTF, improve discharge planning, improve family
engagement and participation in treatment and examine intensive mental health community-based
programs that may be alternatives to residential treatment.
Family-Based Mental Health Services (FBMHS) is an intensive in-home community-based mental health
treatment that is designed to serve children and adolescents that are at risk of out-of-home mental
health treatment. Family-Based Mental Health Services is a team delivered treatment intervention
which combines family therapy, case management, and family support services which may be respite
services or meet basic needs. The program can provide between 6-10 hours a week of service based
upon the way it is authorized, but the service is intended to be flexible and intensive in meeting the
family’s treatment needs. At least one adult caregiver must be willing to participate in treatment. The
family can access family-based services 24 hours per day, 7 days per week. The service is typically
authorized for 32 weeks. FBMHS is the most frequently accessed level of mental health treatment prior
to an out-of-home treatment admission as well as the most frequently recommended and authorized
level of treatment for individuals and their families being discharged from out-of-home treatment.
Dauphin County MH/MR Program Children’s MH staff conducted a chart review of Family-Based Mental
Health Services in February through April 2010. Fourteen (14) charts were reviewed on
children/adolescents that met our target group definition. County staff only reviewed children and
adolescents that had received Family-Based Mental Health Services, during fiscal year 2008-09, and
were admitted to a RTF within 60 days of discharge from Family-Based Mental Health Services. Charts
from five (5) Dauphin County Family-Based Mental Health Service (FBMHS) providers were included in
the review: Philhaven, Catholic Charities, Pennsylvania Counseling Services, Inc., Keystone Children and
Family Services, and Covenant Counseling Services. The individual’s chart from the Case Management
Unit for targeted or administrative case management was also reviewed, if they were active with the
CMU during time they were also receiving Family-Based Mental Health Services.
The purpose of the review was to identify any possible trends for children and adolescents with their
families that have been unsuccessful at FBMHS and were recommended the RTF level of care.
Additionally, Dauphin County MH used the review as a way to gain a better understanding of the
children and adolescents that required a higher level of care and the issues that they and their families
are dealing with.
Highlights of Findings: (See Table for a summary of findings)
A. Each Dauphin County FBMHS provider had a least 1 child or adolescent that were in the RTF
level of care immediately following family-based services. The number of teams involved varied
from provider to provider. A team includes one mental health professional and one mental
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Dauphin County MH/MR Program
Family-Based Mental Health Services
Chart Review Summary
health worker. One provider had a team that had three cases in 2008-09 that were in the target
group reviewed. There was also some changeover in staff during the course of treatment for
some cases. Staff changeovers included a change in both team members and/or a team with
only one team member, not two, for a period of time.
B. The length of treatment in FBMHS was broad with a range from 25 days to 346 days, and the
average length of treatment was about 6 months. Two (2) cases had one extension of services
beyond the initial authorization of 32 weeks (224 days).
C. The average age of the identified person (IP) was 13.64 years old with a range of 9 years old to
15 years old. 50% of the identified children were male and 50% were female.
D. The most frequent primary Axis I diagnosis was Mood Disorder, NOS. 36% (5) of the children
and adolescents’ primary Axis I diagnosis was Mood Disorder, NOS.
E. The family constellation varied across the cases. 28% (4) of the children had single parents. Six
families were a two parent household and of that six, 3 (50%) were adoptive families.
F. All children and teens had mental health services prior to FBMHS. The two most common
services accessed prior to FBMHS were case management (92%) and psychiatric inpatient (92%).
Four (4) or 29% of the families had at least one previous round of FBMHS treatment.
G. 35% of the children and youth reviewed had previous out-of-home treatment. Two were
previously in a Residential Treatment Facility (RTF) and three had previous treatment in a
Community Residential Rehabilitation-Host Home, a treatment home setting.
H. Parents in 69% of the families had mental health and/or substance abuse history. From the
record review, it appeared that the large majority of parents with identified mental health
and/or substance abuse issues were not involved in their own treatment during the time the
family was receiving FBMHS. Fifty –seven percent (57%) of the children and adolescents had
siblings that were also involved in mental health treatment during the delivery of FBMHS.
I.
Treatment plan goals and objectives did not change from month to month in 71% (10) of the
treatment plans. The updating of treatment plan goals and objectives occurred infrequently.
79% (11) of families did not complete any goals or objectives. The average length of treatment
for the 11 individuals and their families that did not complete any goals or objectives was 178
days with a range of 96 days to 346 days. One family out of the 14 cases reviewed was reported
to have successfully completed FBMHS by the provider.
J.
At least one adult caregiver was involved in FBMHS treatment, but in many families other
members of the household had limited participation. The review of progress notes reflected
that in 36% (5 cases) all family members (identified child/adolescent, adult caregiver(s), and
siblings) were involved in treatment.
K. Families received 1-3 sessions per week. FBMHS were provided at least weekly and in many
cases more frequently. It was difficult to determine from progress notes, if the family need or
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Dauphin County MH/MR Program
Family-Based Mental Health Services
Chart Review Summary
their availability determined number of sessions per week. In most of the charts reviewed the
number of sessions per week for that family did not vary much from week to week based upon
the goals or issues being addressed in treatment or occurring with the individual or the family.
L. 21% (3) of the children and teens did not receive either inpatient or partial hospitalization
treatment while participating in FBMHS. 79% (11) of the children and teens received inpatient
and/or partial hospitalization services during the course of FBMHS. 79% (11) individuals
received inpatient hospitalization treatment with a range of 1 to 4 hospitalizations during the
course of FBMHS and an average of 1.6 hospitalizations. 28% (4) individuals received partial
hospitalization and inpatient treatment while receiving FBMHS with a range of 1-2 partial
hospitalizations and an average of 1.75. As an intensive service FBMHS should be able to meet
all the clinical needs of the individual; however, inpatient and partial hospitalization can occur
concurrently with FBMHS when the individual’s level of need is acute. This should be the
exception and not a common practice.
M. The use of Family Support Services varied. One family had a written Family Support Plan that
was including in the record. One family received respite services. Ten (10) families used family
support services at least one time during treatment. Examples of family support services that
were provided included: rent assistance, utilities, family celebrations, art supplies, and
therapeutic games. FBMHS family support services were not provided to 28% (4) families.
N. The majority of the families had minimal or no community supports in place identified at the
point of intake and at the time of discharge as an outcome of the service. Three (3) children and
youth were involved in two community activities. The chart reflected activities such as:
mentoring program, part-time employment and dance.
O. 11 out of the 14 children were recommended for RTF as a result of an Inpatient hospitalization
(9, 64%) or Partial hospitalization (2, 14%) during FBMHS. FBMHS staff did not have an
alternative recommendation in any of the 11 cases according to the documentation in the
record.
P. 93% (13) of the children were open with Mental Health Case Management services. The
frequency of contact and type of contact (face to face and phone contact) with the FBMHS
team, family and child/adolescent varied from case to case. Case managers’ participation in
FBMHS 30 day treatment team review meetings with families also varied from case to case. MH
case managers monitored the individual’s progress in treatment and assisted the family and
FBMHS with coordination of care.
Analysis and Recommendations:
The chart review of Family Based Mental Health Services provided a better understanding of the families
that receive this intensive level of treatment, as well as, information about what the treatment and
support services look like and how they are provided. The goal of FBMHS is to prevent out of home
treatment for children and adolescents with significant emotional and behavioral issues along with
family support services. The service was designed to use in-home family therapy interventions as an
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Dauphin County MH/MR Program
Family-Based Mental Health Services
Chart Review Summary
alternative to out-of-home treatment. During 2008-2009, according to behavioral health-managed care
data, 387 children and adolescents in Dauphin County received FBMHS. The target group of 14 cases is
a small sample relative to the number of children and adolescents that received FBMHS during the
period of time reviewed. However, the review was informative and areas of improvement can be
identified through the close examination of these cases. The target group captured individuals that
were admitted to RTF immediately following FBMHS, but we can speculate that there are additional
children and adolescents that were admitted to RTF 90 days and 120 days post discharge.
1. The progress notes often showed that the FBMHS team did not feel that out-of-home treatment
could be prevented, and FBMHS would not be effective. If the family-based team or any
member of the treatment team is considering out of home treatment, a team meeting needs to
occur, prior to seeking a recommendation for out of home treatment, to discuss the team’s
concerns and why it is felt FBMHS may not be able to meet the needs of the child/adolescent
and their family. The treatment team will discuss how FBMHS and other team members can
provide the support the family needs in order for the child/adolescent to remain in their home.
2. Based on the review of the progress notes and lack of changes in treatment plans there was not
any documentation that the FBMHS team tried different or new strategies, tools, to change
family dynamics and relationships to prevent out of home treatment.
3. Progress notes and treatment plans did not contain documentation that risk factors were
thought through prior to treatment planning between provider and family with specific
strategies to address risk factors. The development of a structured assessment of risks tool
and/or expanding the FBMHS provider’s assessment tool to include factors that may put a family
at greater risk for out of home treatment would assist in identifying families at risk at the start
of FBMHS. Factors would include: previous out of home treatment (CRR-HH or RTF), family
history of mental health issues and/or drug and alcohol issues, partial and/or inpatient stay
during course of family-based, lack of progress in treatment goals, and low engagement with
community/natural supports. The results of the assessment would be used to target treatment
and provide the intensity of service that the family needs. This tool could be utilized throughout
the course of family-based and should not be limited to the initial 30 day assessment treatment
plan development phase.
4. Only three of the cases reviewed showed any progress in treatment goals and objectives, yet
there was only one instance where an objective was modified in order to make it more
attainable for the family to achieve. Goals and objectives should be individualized to meet the
needs of the child/adolescent and their family. The 30 day treatment reviews are an opportunity
to not only review the treatment plan and document progress, but to modify goals and
objectives so that they are attainable for the family. A series of small successes could help
promote further progress in treatment.
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Dauphin County MH/MR Program
Family-Based Mental Health Services
Chart Review Summary
5. All providers maintain their supervision logs separate from individual’s charts. The supervision
logs documents the weekly review of each case with the clinical director. Supervision logs were
not reviewed as a part of this chart review. Further examination, of supervision logs would
assist in understanding the clinical direction family-based teams were provided regarding each
case. Integrating clinical supervision notes into the individual’s chart would integrate all the
clinical aspects of the case into one location.
6. The high percentage (69%) of parent/caregiver(s) that had a history of mental health issues
and/or substance abuse issues highlights the importance of having FBMHS assist in connecting
caregivers with treatment and supports for their own issues.
7. The FBMHS model requires a minimum of one adult caregiver to participate in treatment. All
cases reviewed had at least one caregiver participate in treatment; however, only 36% (5) of the
cases had all family members (caregiver(s), identified child/adolescent and siblings) participating
in treatment. Strategies around engaging all family members should be explored by FBMHS
providers. An example of best practice included a grandmother that lived outside of the home
was included in treatment and utilized as a support resource for the family.
8. 28% (4) of the cases reviewed did not receive any Family Support Funds through the course of
FBMHS. It is difficult to believe cases where the outcome was RTF could not have benefitted
from Family Support Funds. Developing and reviewing monthly a Family Support Plan with the
family could assist the team in identifying unmet needs with the family. Only one case
reviewed had a written Family Support Plan in the file. Respite should be an element included
in every Family Support Plan. One family received formal respite set up through FBMHS and it
is unclear whether or not any of the families received any type of respite through family
members or friends. Another element of the Family Support Plan should explore identifying
community and natural supports.
9. 79% of the children/adolescents had at least one partial and/or inpatient hospitalization
treatment during the course of family based. This percentage was higher than anticipated.
Survey tool did not capture reason for hospitalization. Further examination of reason for
hospitalization and whether it related to what was occurring in treatment would be helpful in
determining how to address this issue.
10. 71% (10) of the cases reviewed utilized the on call or crisis component of FBMHS at least on one
occasion and 7 of the 10 cases received a face to face contact as a result of the crisis. The
survey tool tracked number of on call/ crisis contacts and did not track dates of contacts.
Therefore, it is unclear how many of the face to face contacts resulted in a de-escalation of the
situation and how many involved facilitation of an inpatient hospitalization stay. Further
examination of this area is needed to determine if increasing de-escalation skills of FBMHS is an
area that needs improvement.
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Dauphin County MH/MR Program
Family-Based Mental Health Services
Chart Review Summary
11. 79% of RTF recommendations came from the treating psychiatrist on partial or inpatient units.
Reason for further examination of partial and inpatient unit communication and collaboration
with FBMHS team during course of stay as well as discharge planning is needed. In all cases,
FBMHS was in agreement with RTF recommendation and the progress notes did not indicate
that there was an alternate plan of continuing to support the individual in their home
developed. During inpatient and partial treatment, FBMHS needs to collaborate with the
inpatient or partial program and family to develop a plan to support the individual in their home
and their community.
12. Primary Axis I diagnoses varied. The most common primary diagnosis was Mood Disorder NOS,
5 cases, and the next most common was ADHD and Depressive Disorder NOS with 2 cases each.
There were five other diagnoses with 1 case each. Based on the range of diagnoses, the
individual’s diagnosis does not seem to be a significant factor in whether or not FBMHS can or
cannot meet the family’s needs. Other factors are attributed to accessing out of home
treatment.
13. 13 out of the 14 cases reviewed were known to the CMU. The number of contacts with FBMHS
and child/adolescent and their family varied greatly from case to case. Reviewing the progress
notes and Case manager service documentation demonstrated a lack of consistency in roles
between family-based and CMU. It appeared to vary from team to team and case manager to
case manager. Follow-up is needed with CMU to explore the role of the MH case manager when
FBMHS is involved further and how the case manager can be used to assist the family and
FBMHS in maintaining the child/adolescent in their home and community.
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