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Acute Mental Health Care Services for Children in Pinellas County (Florida). Annette Christy, Ph.D. John Petrila, J.D., LL.M Kristen Hudacek, Psy.D. Diane Haynes, M.A. Department of Mental Health Law and Policy Louis de la Parte Florida Mental Health Institute Community Partner

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Acute Mental Health Care Services for Children in Pinellas County (Florida)

Annette Christy, Ph.D.

John Petrila, J.D., LL.M

Kristen Hudacek, Psy.D.

Diane Haynes, M.A.

Department of Mental Health Law and Policy

Louis de la Parte Florida Mental Health Institute

Community Partner

Personal Enrichment Through Mental Health Services

Thomas Wedekind, ACSW

Anne Pulley, B.S.


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Acknowledgement County (Florida)

This project was funded by the USF Collaborative for Children, Families and Communities with Funds from the Pinellas County Juvenile Welfare Board

The Pinellas County specific archival data analyses were made possible by the Pinellas County Data Collaborative

Portions of the Baker Act data processing and entry were funded by a National Institute of Mental Health Grant to Paul Stiles (R01MH060217)


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The burden of suffering experienced by children with mental health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

The Report of the Surgeon General’s Conference on Children’s Mental Health, Satcher, 2001, p. 3


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Study Components health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

Review of records for 35 children who had a recent Baker Act examination

Archival Database Analysis

Statewide

Analysis of Baker Act Data

Analysis of Medicaid and FL Department of Children and Families claims data

Pinellas County

The above sources, plus…..

Additional data sources available via the Pinellas County Data Collaborative


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Baker Act Examinations health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

The Baker Act is the term applied to Florida’s civil commitment statute

Individuals can undergo a short-term, involuntary psychiatric or “Baker Act” examination of up to 72-hours if:

The are a person with mental illness

There is evidence of harm to self, harm to others and/or self neglect

Examinations may be initiated by:

law enforcement officials

mental health professionals

judges

Individuals are examined in ~115 Baker Act Receiving Facilities that are designated by the Florida Department of Children and Families


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Baker Act Reporting Center health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

Legislative reforms were implemented in 1996 in response to elder abuse related to Baker Act examinations

A form documenting each examination was required to be sent to the Florida Agency for Healthcare Administration

FMHI agreed to serve as the repository for these data and has been receiving data from 1997 to present

These are data on short-term examination (not longer term commitment)

Florida is the only state to have a central repository of client level data on short-term, involuntary psychiatric examination


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Baker Act Data health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

From 1997 to present the Baker Act reporting center has received over ½ million Baker Act examination forms.

We currently receive over 100,000 forms annually

This represents approximately 430 forms received on average every business day

Approximately 16% of forms received are for examinations of children

~80,000 forms received documenting examinations for children from 1997 through 2002

~17,000 forms documenting examinations for children likely received in 2003


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Volume of Baker Act Data health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

  • # of forms received

  • 1997: 69,235

  • 1998: 73,900

  • 1999: 78,064

  • 2000: 83,989

  • 2001: 95,900

  • 2002: 105,046

  • 2003: ~109,000


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Percentage Baker Act Data Adults vs. Children health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.Statewide

Data for children represented 15-17% of the data received in the past 3 and a half years


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Record Reviews health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.


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  • 35 Children from the PEMHS Crisis Stabilization Unit health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

  • Parent/Guardian Consented

  • Children Assented (only after permission from parent/guardian to approach child)

  • First two months focused on consenting only children in the foster care system

  • Due to time and cost constraints, then attempted to consent/assent every child

  • Review of PEMHS record for the Baker Act examination from which the child was recruited into the study

Record Reviews


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  • 40% (n = 14) of children had a history of abuse health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

    • 26% (n = 9) sexual abuse

    • 23% (n = 8) physical abuse

    • 11% (n = 4) emotional abuse

  • The most common presenting problem was suicidal ideation/gestures (n = 19; 54%)

  • Just prior to their examination 80% of children (n = 28) were living with family

  • Children had between one and four Axis I diagnoses (Mean = 2.31)

Record Reviews


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Diagnosis health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

N

%

Adjustment Disorder

15

42.86

Depression

15

42.86

Oppositional Defiant Disorder

9

25.71

Conduct Disorder

8

22.86

ADHD

8

22.86

Bipolar Disorder

7

20.00

Intermittent Explosive Disorder

6

17.14

Post Traumatic Stress Disorder

5

14.29

Dysthymic Disorder

4

11.43

Anxiety

1

2.86

Psychosis

1

2.86

Schizoaffective Disorder

1

2.86

Record Reviews - Diagnoses


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  • The most common referral sources were: health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

    • Police 34% (n = 12)

    • Medical Facilities 34% (n = 12)

Record Reviews


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  • The most common referral sources were: health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

    • Police 34% (n = 12)

    • Medical Facilities 34% (n = 12)

  • 43% (n = 15) had past or current justice system involvement

Record Reviews


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  • The most common referral sources were: health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

    • Police 34% (n = 12)

    • Medical Facilities 34% (n = 12)

  • 43% (n = 15) had past or current justice system involvement

  • 46% (n = 16) had past or current substance abuse documented

Record Reviews


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  • The most common referral sources were: health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

    • Police 34% (n = 12)

    • Medical Facilities 34% (n = 12)

  • 43% (n = 15) had past or current justice system involvement

  • 46% (n = 16) had past or current substance abuse documented

  • Insurance Status

    • 51% Private Insurance

    • 26% Medicaid as Primary (6% as Secondary)

Record Reviews


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  • The most common referral sources were: health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

    • Police 34% (n = 12)

    • Medical Facilities 34% (n = 12)

  • 43% (n = 15) had past or current justice system involvement

  • 46% (n = 16) had past or current substance abuse documented

  • Insurance Status

    • 51% Private Insurance

    • 26% Medicaid as Primary (6% as Secondary)

  • 63% Receiving TANF benefits at time of exam

Record Reviews


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Medication health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.

N

%

Medication

N

%

DDAVP

desmopressin acetate

11

31.43

Zyrtec

1

2.86

Trileptal

9

25.71

Zantac

1

2.86

Risperidal

9

25.71

Wellbutrin

1

2.86

Lexapro

8

22.86

Prozac

1

2.86

Zoloft

6

17.14

Prolixin

1

2.86

Depakote

6

17.14

Lithobid

1

2.86

Strattera

4

11.43

Haldol

1

2.86

Paxil

4

11.43

Effexor

1

2.86

Pamelor

4

11.43

Cogentin

1

2.86

Tenax

3

8.57

Avitan

1

2.86

Seroquel

3

8.57

Atenolol

1

2.86

Vistaril

2

5.71

Abilify

1

2.86

Desyrel

2

5.71

Record Reviews - Medications


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32 children had ssn’s necessary for identification of Baker Act Data

Record Reviews – Baker Act Data


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32 children had ssn’s necessary for identification of Baker Act Data

These 32 children had 56 examinations over a period of almost three years

Record Reviews – Baker Act Data


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32 children had ssn’s necessary for identification of Baker Act Data

These 32 children had 56 examinations over a period of almost three years

Certificate Type

57% (n = 32 exams) Law Enforcement

41% (n = 23 exams) mental health professional

2% (n = 1) judge

Record Reviews – Baker Act Data


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32 children had ssn’s necessary for identification of Baker Act Data

These 32 children had 56 examinations over a period of almost three years

Certificate Type

57% (n = 32 exams) Law Enforcement

41% (n = 23 exams) mental health professional

2% (n = 1) judge

Evidence Type

88% (n = 49) Harm 2% (n = 1) Harm and Neglect

9% (n = 5) Neglect 2% (n = 1) No Evidence type

Record Reviews – Baker Act Data


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32 children had ssn’s necessary for identification of Baker Act Data

These 32 children had 56 examinations over a period of almost three years

Certificate Type

57% (n = 32 exams) Law Enforcement

41% (n = 23 exams) mental health professional

2% (n = 1) judge

Evidence Type

88% (n = 49) Harm 2% (n = 1) Harm and Neglect

9% (n = 5) Neglect 2% (n = 1) No Evidence type

Harm Type

66% (n = 33) harm to self

24% (n = 12) harm to self and others

8% (n = 4) harm only

Record Reviews – Baker Act Data


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32 children had ssn’s necessary for identification of Baker Act Data

These 32 children had 56 examinations over a period of almost three years

Certificate Type

57% (n = 32 exams) Law Enforcement

41% (n = 23 exams) mental health professional

2% (n = 1) judge

Evidence Type

88% (n = 49) Harm 2% (n = 1) Harm and Neglect

9% (n = 5) Neglect 2% (n = 1) No Evidence type

Harm Type

66% (n = 33) harm to self

24% (n = 12) harm to self and others

8% (n = 4) harm only

Repeated Examinations

1 exam 38% (n = 12) 5 exams: 3% (n = 1)

2 exams: 13% (n = 13) 7 exams: 9% (n = 3)

3 exams: 6% (n = 2)

4 exams: 3% (n = 1)

Record Reviews – Baker Act Data



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1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

Archival Database Analyses


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1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

Repeated Examinations

1 exam: 67% 4 exams: 3%

2 exams: 18% 5 or more: 5%

3 exams: 6%

Archival Database Analyses


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1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

Repeated Examinations

1 exam: 67% 4 exams: 3%

2 exams: 18% 5 or more: 5%

3 exams: 6%

Gender: 50% Male Age: Average age at time of first examination = 13.60 years

Archival Database Analyses


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1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

Repeated Examinations

1 exam: 67% 4 exams: 3%

2 exams: 18% 5 or more: 5%

3 exams: 6%

Gender: 50% Male Age: Average age at time of first examination = 13.60 years

Certificate Type

62% Law Enforcement

33% Mental Health Professional

4% Judges

Archival Database Analyses


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1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

Repeated Examinations

1 exam: 67% 4 exams: 3%

2 exams: 18% 5 or more: 5%

3 exams: 6%

Gender: 50% Male Age: Average age at time of first examination = 13.60 years

Certificate Type

62% Law Enforcement

33% Mental Health Professional

4% Judges

Evidence Type

89% Harm Only

5% Neglect Only

4% Both Harm and Neglect

1% Evidence Type Missing

Archival Database Analyses


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Baker Act Exams for Children in 2002 – By Month three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County ResidenceStatewide


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Data Set three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

Label

General Description of Data

Baker Act

BA

A statewide database containing information about short-term, involuntary psychiatric examinations

Child Welfare

Data only available from July 1999 to Nov 2000

CW

A statewide databases containing child (only) information on abuse allegations and demographics (founded/unfounded investigation, type of abuse and results or actions taken)

Emergency Management System

EMS

Pinellas County-wide emergency medical service information system containing demographic and situational information on 911 calls where ambulance was sent out, whether or not someone was transported via ambulance.

Department of Children and Families Integrated Data System

IDS

An automated data system of the Florida Department of Children and Families containing information about alcohol, drug abuse & mental health services at state funded providers.

Medicaid Claims

MDC

A statewide database containing Medicaid physical and Mental health claims data

Pinellas County Cross System Analysis


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N three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

CW

IDS

MDC

EMS

All Children

1,559

27.33%

72.61%

40.99%

27.33%

Girls

778

31.75%

68.51%

38.43%

31.75%

Boys

781

22.92%

76.70%

43.53%

22.92%

The majority of children with a Baker Act examination in the three fiscal years also had data in one of the four other data systems

18% - only Baker Act data 8% - 3 other data systems

31% - 1 other data system 14% - 4 other data systems

29% - 2 other data systems

Pinellas County Cross System Analysis


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Pinellas three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County ResidenceStatewide

41% 40% Crisis Support/Emergency

41% 35% Crisis Stabilization

18% 42% Medical Services

18% 36% Outpatient Individual

18% 19% Treatment Alternatives for Safer Communities

17% 34% In Home and Onsite Services

16% 40% Case Management

6% 25% Assessment

6% 6% Substance Abuse Detoxification

5% 17% Intervention

5% 2% Intensive Case Management

Archival Analyses – IDS DataFiscal Years 1999, 2000 and 2001


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% Children w/ Service Cost and % of Total Cost three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

Pinellas StatewidePinellasStatewide

TOTAL COST FOR 3 YEARS$8.2 M $208 M

78% 61%Counseling Therapy and Treatment Services $505,000 $6.5 M

5.2% 3.1%

76% 65% Evaluation and Testing Service $155,000 $3.6 M

1.6% 1.8%

74% 57%Treatment Planning and Review $113,000 $1.7 M

1.2% 0.8%

45% 39%Targeted Case Management $1.7 M $22.8 M

17.6% 11.0%

40% 36%Children’s Behavioral Health $1.2 M $16.9 M

12.1% 8.1%

36% 28% Child Ancillary Inpatient Services $75,000 $1.8 M

0.8% 0.9%

Archival Analyses – Medicaid DataFiscal Years 1999, 2000 and 2001


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% Children w/ Service Cost and % of Total Cost three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

PinellasStatewidePinellas Statewide

34% 21% Hospital Outpatient Mental Health Services $96,000 $1.8

1.0% 0.9%

33% 39%Physician’s Services $24,000 $497,000

0.3% 0.3%

26% 28%Child Inpatient Care ` $1.7M $50.0 M

17.8% 24.1%

26% 17%Other Mental Health $74,000 $894,000

0.8% 0.4%

25% 22%Emergency Mental Health Services $18,000 $1.0 M

0.2% 0.5%

24% 21%Physician’s Services Clinic or Outpatient $16,000 $497,000

0.2% 0.2%

Archival Analyses – Medicaid DataFiscal Years 1999, 2000 and 2001


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% Children w/ Service Cost and % of Total Cost three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

PinellasStatewidePinellasStatewide

19% 37%Lab with Mental Health Diagnosis $4,400 $376,000

0.1% 0.2%

17% 20%Rehabilitative Services $115,391 $2.7 M

1.2% 1.3%

13% 13%Behavioral Health Overlay Services $608,057 $10.3 M

6.3% 5.0%

10% 16% Day Treatment Services $154,478 $6.3 M

1.6% 3.1%

6 % 5%Therapeutic Foster Care $1.5 M $22.3 M

15.9% 10.8%

6% 4% Substance Abuse Inpatient $156,368 $35.0 M

1.6% 1.7%

Archival Analyses – Medicaid DataFiscal Years 1999, 2000 and 2001


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7 Key Findings three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence


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Key Finding #1 – System Findings three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

Multiple programs are accessed by children at PEMHS

The type and timing of the services are based on factors such as whether children are in the dependency system, their legal status (voluntary vs. involuntary), their needed level and type of care, and availability of services

Interaction of staff from PEMHS and from the Family Continuity Program (FCP) is key to the access and continuity of care for some children


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Key Finding #2 – Certificate and Evidence Type three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

Baker Act examinations of children were more likely to be initiated by law enforcement officials and to be based on evidence of harm than examinations for adults, suggesting that a focus on factors related to law enforcement initiated Baker Act examinations would help us to better understand examinations of children and associated factors


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Key Findings #3 - Seasonality three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

The number of Baker Act examinations for children was less in the summer, both statewide and for Pinellas County

Although cause and effect cannot be determined from this correlational finding, they suggest some seasonality in Baker Act examinations for children and is highly suggested that school is involved in this seasonality


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Key Findings #4 – Repeated Examination three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

Thirty-three percent of the children with a Baker Act examination over a three-year period in Pinellas County experienced more than one examination during this time period

Focused attention on this subset of children with multiple involuntary examinations is warranted, given that the purpose of crisis stabilization units is to offer emergent care – not the longer term care that may be needed by many of these children

Multiple examinations may suggest discontinuity of care

Additional focus on this subpopulation could yield information about the causes of repeated examinations and ways to intervene to prevent them


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Key Findings #5 – History of Trauma three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

The finding that 40% or the children from the case studies had experienced sexual, physical and/or emotional abuse suggests that trauma is an important factor to address when planning and implementing care for some children who receive acute mental health care


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Key Findings #6 – Therapeutic Foster Care three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

The 41 children who experienced at least one Baker Act examination over a three-year period in Pinellas County who also had Medicaid reimbursed therapeutic foster care accounted for 6% of the children with Medicaid reimbursed services, but their therapeutic foster care reimbursed care of over $1.5 million accounted for almost 16% of the cost of Medicaid reimbursed services

Almost 5% of children statewide with at least one Baker Act examination over a three-year period had Medicaid reimbursed therapeutic foster care services, at a cost of over $22 million representing almost 11% of Medicaid reimbursed services

The high cost of these services for a relatively small number of children, particularly in Pinellas County compared to statewide, suggests that a focus on healthcare needs for children in this group may be warranted

This may be particularly important within the current context of privatization of foster care across Florida and the focus on integration of the foster care and behavioral health care system


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Key Findings #7 – Intensive Case Management three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

  • The use of case management and intensive case management is lower than we expected for the population of children who had contact with the involuntary, acute-care system

  • For example:

  • At least one case management claim over three years:

  • 16% Pinellas

  • 40% Statewide

  • At least one intensive case management claim over three years:

  • 5% Pinellas

  • 2% Statewide


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Contact Information three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

Annette Christy - [email protected] - 813-974-7419

FMHI: http://www.fmhi.usf.edu

Baker Act Reporting Center: http://bakeract.fmhi.usf.edu

Click on “Documents” link to go to page with pdf file of complete report

Collaborative for Children, Families and Communities: http://usfcollab.fmhi.usf.edu/


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