text:
System of Care Approaches in Residential Treatment Facilities Serving Children with Serious Behavioral Health Needs
- Michael Spencer
- 3 years ago
- Views:
1 CHCS Center for Health Care Strategies, Inc. System of Care Approaches in Residential Treatment Facilities Serving Children with Serious Behavioral Health Needs Issue Brief Kamala D. Allen, Center for Health Care Strategies; Sheila A. Pires, Human Service Collaborative; and Jonathan Brown, PhD, Mathematica Policy Research M ARCH 2010 P roviding an appropriate continuum of mental health services for the estimated one in five children and adolescents in the U.S. who have a mental health disorder is imperative. 1 While it is well established that such services should emphasize community-based care, 2 children and youth with challenging behavioral health problems are often placed instead in residential treatment facilities (RTFs). Those in residential treatment settings can benefit from a system of care approach that facilitates coordination between residential and community-based providers and engages youth and their families as partners in care. A system of care is a strengths-based approach that recognizes the importance of family, school and community, and addresses the physical, emotional, intellectual, cultural, linguistic and social needs of every child and youth. Through this approach, families and youth work with public and private organizations to design a coordinated network of community-based services and supports improving functioning at home, in school, and in the community. 3 The federal Comprehensive Community Mental Health Services Program for Children and Their Families has funded systems of care for children s mental health in states, tribes and communities across the country, with demonstrated improvements in behavioral and emotional health. 4 Insufficient home- and community-based options, financial incentives that drive residential placements, and reduced use of inpatient psychiatric care all contribute to increases in the use of RTFs. 5 Accordingly, it is vital to understand how these facilities are delivering mental health services to children and youth to begin to address questions about RTF overuse, lengths of stay, long-term effectiveness, and adoption of evidence-based principles of care. 6 This paper describes the findings of a national survey of RTFs that serve children and youth with serious behavioral health challenges. The survey sought to identify the extent to which: System of care principles are reflected in the policies and practices of RTFs; and Residential treatment is providing home- and community-based services and supports in addition to traditional offerings. Survey findings are particularly relevant to Medicaid and other public purchasers of residential treatment, given the high cost of residential care, its history of overuse, and the potential for home- and community-based services to reduce inappropriate RTF placements and lengths of stay. The findings can also inform child behavioral health policymakers, RTF providers, and child and family advocates seeking promising approaches to better meet the extensive behavioral health needs of children and youth in this country. The intent is that these findings catalyze discussion among these constituencies to increase incorporation of system of care principles and practices throughout the continuum of care, particularly in RTFs, where they are needed most. This issue brief is made possible through support from the Substance Abuse and Mental Health Services Administration s Center for Mental Health Services and the Annie E. Casey Foundation. System of Care Approaches in Residential Treatment Facilities Serving Children with Serious Behavioral Health Needs 1
2 Survey Partnership While systems of care emphasize home- and community-based services, their growing use has coincided with increased reliance on RTFs driving tension between advocates of communitybased and residential care. The reasons are many, including limited resources, differing philosophies, and a lack of research demonstrating the effectiveness of residential treatment. Based on mutual concern about these issues, the Child and Family Branch of the Substance Abuse and Mental Health Services Administration s (SAMHSA) Center for Mental Health Services (CMHS), the Annie E. Casey Foundation, and the Center for Health Care Strategies (CHCS) engaged Mathematica Policy Research to conduct this survey. This effort follows CMHS Building Bridges Initiative, launched in 2006 to create partnerships and improve relationships among residential and community service providers, families and youth. The Building Bridges Initiative encourages community-based and residential providers to better communicate and coordinate their services within a system of care framework. 7 Survey Methodology Development of the Survey of Residential Treatment Facilities ( RTF survey ) was guided by an advisory panel of parents, youth, RTF directors, policymakers, advocates, researchers, and other community-based providers, as well as key-informant interviews. Survey items were designed to gather information on RTF: (1) characteristics; (2) values and principles; (3) treatment and assessment practices; (4) workforce needs; (5) cultural and linguistic diversity; (6) relationships with other providers; and (7) financing. The RTF survey was distributed from April through June 2009 to individuals (primarily RTF directors) who had completed the 2008 SAMHSA National Survey of Mental Health Treatment Facilities (NSMHTF). * The NSMHTF included 741 facilities that provide 24-hour residential treatment to children and adolescents age 17 or younger. For those directors responsible for more than one RTF, one facility was selected randomly to avoid overburdening the respondent and/or over-representing any one organization in the findings. This reduced the number of eligible facilities to 611. Each RTF director received an invitation to complete an online survey (a paper version was also available), requiring approximately 30 to 45 minutes to complete. Respondents did not receive compensation or an incentive to complete the survey. Non-respondents received up to four reminder s and two telephone calls to encourage participation. Sixty-seven individuals (11%) who were invited to complete the survey responded that their facility does not provide residential treatment and/or does not serve children or adolescents. Among those remaining (n=544), 293 (54%) completed the survey. This paper reports on their responses. NSMHTF data revealed no statistically significant differences between facilities responding and not responding to the RTF survey in terms of the number of children and youth served, type of ownership, religious affiliation, accepted forms of payment, or provision of free treatment. Fifty-six percent of those completing the RTF survey are directors of non-profit facilities, and 44% direct forprofit facilities. Highlights of Survey Results Survey results indicate both evidence of and opportunities for improvement in the incorporation of system of care values in RTF policies and practices, and an orientation to community-based care. * RTFs that operate under the auspices of child welfare were only included in the NSMHTF if they offer mental health treatment services. 2
3 Most respondents largely private non-profit or commercial entities provide a range of residential and non-residential mental health services for children and youth; a few also provide substance abuse services; and many report providing trauma-informed care. The vast majority report mechanisms in place to ensure appropriate residential placement, yet only about half work with referring agencies to determine whether alternative programs might be more appropriate. While nearly all develop individualized treatment plans, the role of youth and families in creating these plans varies greatly, and very few provide family or youth peer support. Staff recruitment and retention is challenging, and only a few respondents believe that their staff has a solid understanding of youth-guided and family-driven principles. RTFs largely report having policies to reduce seclusion and restraint, though most had used the practice in the previous year. About half of RTFs do predischarge planning to transition children and youth from their facilities, and a similar proportion assist youth with the transition to adult services. Staff training on the use of culturally competent services and supports is almost universally provided, but application is uneven and some important cultural groups are rarely addressed. Fewer than half of RTFs collect outcomes data, and not for very long following discharge. Additionally, most RTFs surveyed receive Medicaid and child welfare funding, however very few have performance-based contracts. Detailed Survey Findings Description of Facility Types Survey results reflect the trends of decreasing government ownership of residential beds for children and increasing commercial and non-profit ownership. Eighty percent of reporting RTFs are owned by private partnerships or corporations; only 5% are government-owned. Among non-government owned RTFs, 83% are non-profit or not-for-profit, and 16% are affiliated with a religious organization. Respondents described their primary service area as mental health (68%); substance abuse (4%); a mix of mental health and substance abuse (17%); and other (11%). Over the past decade, RTFs increasingly have diversified their service offerings, ** a trend borne out by the survey results. Sixty-six percent of respondents report that they provide both residential and nonresidential mental health services. The reporting facilities encompass a range of nine to 100 beds (median=38, mean=48). Licensing and Accreditation Status Given the growing federal emphasis on health care quality and accountability, the survey explored facility licensing and accreditation. Most reporting RTFs are licensed by either the state mental health authority (59%) and/or the state department of health (48%), and 79% have some national accreditation. Fifty-three percent are licensed or certified as a psychiatric residential treatment facility according to federal Centers for Medicare and Medicaid Services (CMS) requirements; 13% of respondents do not know whether they are so licensed or certified. Thirty-six percent are accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO); 32% by the Council on Accreditation for Children and Family Services (COA); 10% by the Commission on Accreditation of Rehabilitation Facilities; and less than 1% by the National Committee for Quality Assurance (NCQA). Population Served Population data submitted by respondents are consistent with other studies showing that older children and youth are more likely to be served in RTFs than younger children. 8 Eleven percent of respondents serve children under the age of 6 years, 57% serve children ages 6 to 12, 93% serve Trauma-informed care treats the consumer in the context of the trauma-inducing situations he or she has experienced and uses that information to inform the approach to care. Where the response rate for a given question was less than 90% (263 or fewer), the number of respondents is indicated. The remaining 15% of respondents reported their facility ownership as other. ** Examples include East Ming Quong in Campbell, CA; Youth Villages in Nashville, TN; and Boysville in Converse, TX. System of Care Approaches in Residential Treatment Facilities Serving Children with Serious Behavioral Health Needs 3
4 adolescents ages 13 to 18, and 21% serve adolescents and young adults ages 19 to 25. Respondents estimate that 25% of those served were diagnosed with co-occurring mental health and substance abuse disorders. This contrasts with a recent study finding that at admission, 91% of children and youth in residential treatment had mental health diagnoses and 70% had alcohol/substance abuse diagnoses, 9 suggesting a high level of co-occurring disorders. During the previous 12 months, the total number of children served by reporting facilities ranged from 10 to 290 (median=83, mean=97). The daily census ranged from 0 to 264 (median=34, mean=45). Efforts to Ensure Appropriate Placement How RTFs determine appropriateness of placement and continued stay is an issue of great interest in the children s mental health field. Ninety-two percent of 261 facilities responding report that they consult with staff from a referring agency (e.g., the mental health authority, child welfare, or schools) before a youth enters treatment. Those who do not consult with referring agencies indicate that other agencies do not engage in consultation or lack appropriate records, or that RTFs are not reimbursed for such consultation. Only two respondents believe that information from the referring agency is unnecessary. The majority of RTFs help the referring agency determine bed availability and appropriateness of placement the latter largely through a review of available records and evaluations (100%), discussion with the referring agency (79%), and/or a formal assessment of the youth s functioning (70%). Of those making functional assessments through a formal evaluation, 59% do so with a widely recognized, standardized instrument, such as the Child and Adolescent Functional Assessment Scale (CAFAS). 10 Staff at 46% of RTFs participate in treatment planning meetings at other agencies to discuss treatment needs of youth who have been or will be referred. Virtually all respondents (99%) report that they conduct periodic reassessments to determine whether continued residential treatment or a transition to community-based services is appropriate. For 77%, this reassessment is triggered by evidence of the youth s improvement, 71% perform reassessment at every treatment team meeting, and 44% do so upon request of the youth or family. Respondents use a number of practices to monitor ongoing need for placement. Ninety-six percent assess the youth s therapeutic response to residential treatment, 93% gather information about treatment preferences directly from the youth, and 89% gather it from the family. Other common practices are consulting with community providers to determine appropriateness (63%) or availability (68%) of community-based services. Of the 236 responding, 31% conduct in-home evaluations of the family environment after admission. Relationship with the Courts Courts often play a key role in placement of children in RTFs, mandating placements as part of the disposition process. Most of the RTFs (63%) are not legally or contractually required to accept some or all youth referred for placement, including those referred by the courts. Of 261 facilities responding, 79% receive referrals from family courts or the juvenile justice department. The vast majority of these (94%) evaluate the referrals to ensure that appropriate treatment can be provided, and more than half (61%) work with community agencies to determine whether home- or community-based services are more appropriate for a child s needs. Slightly more than one-third (36%) do not conduct further evaluations for court-referred youth, either because they must accept these referrals without further evaluation (14%) or because the court has already determined that residential treatment is required (28%). Transition from Residential to Home- or Community-Based Services One of the concerns about out-of-home placements is the extent to which youth and their families receive support for a smooth transition back to more natural living and school environments. Of the 261 RTFs responding, 53% begin working on a client s discharge plan upon admission; 26% prior to 4
5 admission; 15% during team meetings immediately following admission; and 6% after the youth shows signs of improvement. Figure 1: Members of Treatment Planning Teams Members RTFs Including* Almost all respondents (98%) offer some service to facilitate Treatment facility staff 97% the transition from residential to home- or community-based Youth 94% services. The most common activities reported are consulting with educational institutions to plan for education (76%); Family members 92% referring to natural helpers such as family/youth peer support Referring agencies 85% groups (68%); consulting with other agencies/providers to Natural helpers 40% locate appropriate housing (63%); and accompanying youth to *Of those using treatment planning teams. outpatient or other community services (58%). Thirty-four percent consult with employers to identify vocational opportunities, and 31% conduct in-home evaluations of the family or living situation. In addition, the majority of respondents (57%) report that there are some services in the community to help youth transition out of residential treatment, but suggest that these are not adequate. About a quarter (24%) indicate that there are very few or no such services, while 19% note that their communities offer a comprehensive range of transition services. Transition services are especially critical for older youth who are moving into adult service systems, in order to maintain the continuity of care that their conditions require. 11 Of the 258 RTFs responding, 54% provide services to help youth ages 18 to 25 transition to adult services. Eighty-one percent of those provide telephone or written referrals; 79% provide contact information for adult service providers; 75% meet with community-based agencies that help young adults find treatment services, vocational assistance, education, and housing; and 29% provide community-based treatment services. Individualized Treatment Planning Individualized treatment plans are a hallmark of systems of care. Virtually all responding RTFs (99%) report that they develop individualized treatment plans for youth. Most incorporate system of care principles including: outcomes reflecting the input of the youth and family; a strengths-based approach to care; an individualized crisis/safety plan; and transition strategies. Sixty-eight percent employ strategies for incorporating natural helpers in the plan of care. Ninety-four percent of respondents also indicate that their individualized treatment planning utilizes a team approach incorporating various members (see Fig. 1). While system of care principles stress the importance of family involvement on the treatment planning team, 12 in only 12% of facilities do families play a primary role in plan development, and in only 17% do youth (see Fig. 2). Figure 2: Level of Family and Youth Involvement on Treatment Planning Teams 79% 78% Approaches to Behavioral Management While most facilities (86%) have policies to reduce the use of seclusion and restraint, 83% used these practices within the previous 12 months. Those who did so indicate that they implement standard debriefing and reporting protocols in conjunction with these practices, including staff debriefing (68%), debriefing with the youth and family (72%), 17% 12% 8% 5% 1% 0% Rare/None Limited Some Primary Family Involvement Youth Involvement System of Care Approaches in Residential Treatment Facilities Serving Children with Serious Behavioral Health Needs 5
6 Figure 3: Intervention Strategies for Behavioral Management Intervention RTFs Utilizing Youth-/family-identified supports and interventions 87% Trauma assessments 73% Use of other agencies intervention strategies 67% Trauma-informed care 64% recording the incident in the treatment plan (71%), and/or reporting to the youth s physician (65%). Respondents engage, as well, in other behavior management approaches, including youth-/familyidentified supports and interventions, trauma assessments, other agencies successful intervention strategies, and trauma-informed care (see Fig. 3). Provision of Non-Residential, Community-Based Services Sixty-two percent of reporting RTFs provide at least one non-residential service (see Fig. 4), and 66% are part of organizations that provide both residential and non-residential, community-based services for children and adolescents. However, only half employ staff who provide continuing clinical services to youth in the community. Use of Family-Driven Practices A central tenet of a system of care approach is the engagement of families as partners in care, which includes facilitating family visitation and children s visits home. All but one responding RTF allow family visitation. Of these, 59% permit family visits at any time, while 22% do so only after a specified period of time following admission. Eighty-four percent allow home visitation. Seventythree percent of those permitting visitation do not allow that right to be taken away as a consequence of unacceptable behavior by the child or youth. Families of children and youth in behavioral health treatment may need support to be effective partners in care. Support provided by respondents (see Fig. 5) includes conference calls (the most common), off-site visits, social events for youth and family, reimbursement for meals during visits, reimbursement for transportation to and from the facility, and family-to-family peer support (provided by less than one-quarter). Of those that offer family peer support, more than half do so for all families, about a third based on staff judgment of usefulness, and the remainder to families upon request. Figure 4: Non-Residential Services Available to Youth Family mentors typically are unpaid. Service RTFs Offering Supported housing 62% Outpatient mental health counseling* 52% Integrated co-occurring treatment 48% Intensive in-home treatment 38% Crisis intervention 37% Family preservation and reunification 35% Multi-Systemic Therapy 38% Therapeutic foster care 23% Supported employment 15% Vocational training 12% Educational tutoring 10% Electroconvulsive therapy 1% *Of those providing outpatient mental health counseling, services include group therapy (95%), cognitive/behavioral therapy (94%), interpersonal psychotherapy (86%), and Functional Family Therapy (44%). 13 Systems of care also call for family and youth involvement with RTF policy and operations. However, the survey found family involvement with RTF governance and facility operations to be minimal. Only 12% of RTFs involve families in programmatic oversight, most often as peer mentors, board members, or liaisons between other families and staff. Fewer than 25% of RTF directors surveyed believe licensing and accreditation standards should require that family members have a governance role. Use of Youth-Guided Practices Engagement of youth as partners and consumer-driven care are key system of care principles. Less than onethird (30%) of respondents offer youth-to-youth peer support; of these, half offer it to all youth, while half do so based on staff judgment of usefulness. Only 12% of RTFs involve youth who have stayed in an RTF in programmatic oversight or operations, most in unpaid 6
7 roles. Similarly, few involve youth as legislative advocates, in marketing, to assist in staff training, or as quality reviewers. Forty-three percent of RTFs have an advisory board or student council of youth currently in residential care. Only about one-quarter (26%) of RTF directors believe that licensing or accreditation standards should require youth involvement in governance. Culturally and Linguistically Competent Services and Supports Figure 5: Types of Family Support Offered Activity RTFs Offering Conference calls 94% Off-site visits 72% Social events for youth and families 70% Reimbursement for transportation for visits 56% Reimbursement for meals during visits 54% Family-to-family peer support 22% Systems of care stress the importance of a culturally and linguistically competent approach to care a critical principle for RTFs, as racially and ethnically diverse children tend to be overrepresented in residential care. 14 Of 261 RTFs responding, 86% indicated that they require training on cultural diversity and/or cultural competency for all treatment staff, and 85% have provided such training on a variety of topics in the previous 12 months (see Fig. 6). Only 34% of 258 responding RTFs have procedures for monitoring the cultural competency of services, most commonly through management review with staff (55%), management discussion of needed improvements (51%); a standing committee or team (46%); and/or management meeting with family members or youth (18%). Of 237 RTFs responding, all have written policies related to the religious practices or faith of residents. The most common of these are provision of time for religious practice (83%); escorting youth to a place of worship in the community (77%); and ensuring that someone is available to talk to youth about their faith and beliefs (59%). A smaller percentage (22%) has dedicated space for religious observance. Just over half of respondents believe that their staff can meet non-english communication needs of children, youth and families involved in behavioral health treatment, either directly or through a translator. Staff Training in Family-Driven and Youth-Guided Care Principles Sixty-five percent of 260 responding RTFs have provided treatment staff with training on how to apply principles of family-driven or youth-guided care, and 71% of 258 RTFs have provided training on its importance. Despite this, only 12% of respondents believe that most of their staff understand and apply principles of family-driven care, and only 19% believe this to be true for youthguided care (see Fig. 7). Staff Recruitment and Retention Sixty-four percent of RTFs report difficulty hiring staff, particularly child care workers and registered nurses, citing a shortage of applicants and the inability to offer competitive salaries. In addition, salary levels hamper staff retention at 56% of facilities. Inadequate staff training may further impede recruitment and retention at these facilities. Figure 6: Cultural Diversity and Competency Training Offered Topic RTFs Offering Racial /ethnic views of mental health treatment 79% Religious diversity and practices 64% Youth lifestyles 61% Mental health needs of GLBT* youth 47% Community resources for GLBT youth 19% New languages 3% *Gay, lesbian, bisexual, and transgender System of Care Approaches in Residential Treatment Facilities Serving Children with Serious Behavioral Health Needs 7
8 Figure 7: Staff Understanding and Use of Family-Driven and Youth-Guided Care Principles 12% 25% 22% 19% 20% 43% Family-Driven Care Understand and apply 21% 38% Youth-Guided Care Understand, but need additional training to apply Are likely aware, but need training to apply Are likely unaware Utilization of Quality Assurance Practices Federal health care agencies have begun to put greater emphasis on the provision of high-quality care for children. 15 Accordingly, RTFs report having a number of quality assurance practices in place (see Fig. 8). Given the system of care emphasis on using data to improve the quality of care, RTF directors were asked about efforts to monitor outcomes following discharge. Of several categories of information, only satisfaction with residential treatment services is collected by more than half (69%)of RTFs. Less than half monitor contact with the legal system, use of other community-based mental health services, housing stability, employment, use of hospital or residential treatment, clinical and functional status, and/or educational attainment. Among those collecting post-discharge data, most do so for no more than six months, and only about onethird share this data with youth and families at admission. Description of RTF Financing Survey data reveal Medicaid s significant role in RTF financing. As reported by 260 respondents, in the past 12 months, RTFs received Medicaid reimbursement for a mean of 69% of youth, and Title IV-E (child welfare) payments for room and board for a mean of 29%. Notably, 19% of respondents did not have knowledge of the extent to which Medicaid is a financing source, and 42% could not report on their facilities reliance on Title IV-E funding. Bundled rates are an alternative and typically more flexible financing mechanism for services provided to children and youth with serious behavioral health needs. By removing service constraints that often arise from a single funding source, bundled rates enable a provider to tailor services to a child s needs. Among 250 respondents, 60% receive bundled rates for some or all of their youth; of those, 42% say the mechanism allows sufficient flexibility to meet care needs. While the health care field has shown an increasing interest in performance-based contracting, this is not reflected in the survey results. 16 Only 21% of 256 reporting RTFs receive financial incentives to reduce lengths of stay. Of these, 72% undergo periodic review of plans of care by state or county officials; in 50%, contracts with the state or county cover specific in-home or community services to help youth transition out of residential treatment; and in another 20%, reimbursement is reduced after a youth has been in residential treatment for a certain period of time. Figure 8: Use of Quality Assurance Practices Practice RTFs Utilizing Regular case reviews with supervisor 99% Periodic client/patient satisfaction surveys 97% Monitored continuing education for staff 94% Periodic utilization review 91% Regular case reviews by quality review committee Client/patient outcome follow-up after discharge 75% 68% Policy Implications To varying degrees, the RTFs responding to this survey have adopted some policies and practices informed by system of care principles, and to a lesser extent, have evolved toward greater provision of home- and community-based services. While there are some promising findings herein, there remains room for improvement in these areas. Reflection of System of Care Principles Family-Driven and Youth-Guided Care Overall RTF adoption of family-driven and youthguided care is limited, and additional staff training in this area appears needed. Nationwide, communities 8
9 implementing systems of care are demonstrating effective partnerships with families and youth at direct service, program operations, and governance levels. In addition, many states and communities have strong family- and youth-run organizations that have grown as systems of care have spread offering valuable lessons. System of care initiatives such as those funded by SAMHSA can reach out to RTFs to help them integrate family-driven and youth-guided principles in their policies and practices. State purchasers such as Medicaid and mental health authorities can include these principles in performance measures, provider capacity-building efforts, and pay-for-performance initiatives. Cultural and Linguistic Competency While virtually all facilities recognize the importance of cultural and linguistic competence and have provided some training in these areas, few facilities monitor cultural competency and/or explore related satisfaction levels of diverse youth and families. Federally funded, national technical assistance centers that support systems of care can help RTFs in building their competency in this area. State purchasers that are concerned about health care disparities can address high rates of RTF placement among racially and culturally diverse youth by working with referring agencies to examine racial biases and expand culturally competent home and community alternatives. Survey results also point to an unmet need to provide culturally competent care beyond language services alone. For example, despite research suggesting that gay, lesbian, bisexual, and transgender (GLBT) youth are at high risk for behavioral health problems, out-of-home placements, and homelessness, low rates of staff training on GLBT issues and community resources were found. 17 In facilities where staff racial and ethnic backgrounds largely do not reflect the individuals they serve, it is particularly important to provide opportunities for community feedback to the cultural competency of specific services. Given the many varied dimensions of culture including race, ethnicity, age, gender, religion, and sexual orientation this is a particular challenge; but if done appropriately, can reduce and/or eliminate barriers to engaging youth and families as partners in care. Youth with Co-Occurring Mental Health and Substance Abuse Disorders Despite the high rate of co-occurring substance abuse in children and youth receiving mental health services, only 17% of RTFs reported that their services focus equally on mental health and substance abuse. This is not surprising given that state purchasers of mental health and substance abuse services often operate independently with different licensing, contracting and financing processes. State purchasers can change purchasing and financing approaches to encourage integrated co-occurring treatment, which is critical and more effective than non-integrated treatment for this population. 18 Home- and Community-Based Services and Supports Although most facilities discuss appropriateness of placements with referring agencies, it was notable that only about half explore home- and community-based alternatives with these agencies. Furthermore, over one-third of the facilities that accept court-referred youth do so with little discussion of appropriateness. Adoption of strengths-based screening tools and individualized service planning approaches by RTFs, referring agencies and the courts could help to ensure that home and community alternatives are appropriately considered. Most facilities either provide or are part of larger organizations that provide non-residential, community-based services. While there were promising reports of capacity to provide intensive inhome services, family preservation, crisis services, and evidence-based practices such as Multi- Systemic Therapy and Functional Family Therapy, a minority of reporting facilities provide these services, vocational training or supported employment. State purchasers can address this by including RTFs in efforts to encourage provider adoption of evidence-based and effective practices. System of Care Approaches in Residential Treatment Facilities Serving Children with Serious Behavioral Health Needs 9
10 To enhance their provision of system of care informed services and supports, RTFs should consider incorporating related principles into their missions and visions. Frequent staff training that is designed to increase both the understanding and practice of youth-guided and family-driven care is essential given the high turnover rates among RTF staff. Additionally, enabling youth and families to be full partners in treatment planning and goal setting garners their commitment to the plan, and promotes use of informal and natural supports. Outcomes, Quality, and Financing Attention to quality of care, the monitoring and reporting of outcomes, and accountability in general are areas warranting more focus by RTFs. Few track outcomes such as clinical and functional measures, recidivism, school or employment status, or housing stability, and with short tracking periods. It is not surprising, then, that few share outcomes data with families and youth at the time of admission. Despite Medicaid s emphasis on quality and performance measurement, and its role as a major funding source for RTF services, most RTFs reportedly are not bound by performance- or incentivebased contracts tied to desired outcomes (such as reduced lengths of stay) promoted in a system of care. As a result, RTFs do not have strong financial incentives to pursue interventions such as evidence-informed home and community alternatives that focus on these outcomes. State purchasers could require RTFs to track and monitor key system-, child- and family-level outcomes as part of their quality improvement initiatives. The majority of facilities have national accreditation, and nearly all are licensed by their respective states. Those that have national accreditation are most likely to be accredited by JCAHO, which employs a model that is more medically than socially oriented, and/or by COA, which has standards more closely reflecting system of care values. State purchasers could increase the rates of national accreditation particularly from COA through contract requirements, purchasing specifications and pay-for-performance measures with RTFs. Areas for Future Inquiry There are a number of questions that ideally would have been included in the survey, but were omitted to prevent an undue burden on respondents. For example, given widespread interest among child behavioral health advocates, youth and families, and policymakers in the average length of stay (ALOS) for children and youth in RTFs, it would have been of interest to determine whether greater adherence to system of care principles corresponds to shorter ALOS. Other areas of interest include the primary sources of referrals to RTFs and how those differ by state or region, and the use of evidence-informed practices such as wraparound in RTFs. The current findings and remaining questions suggest that further study is warranted to better understand the approach of RTFs to services and supports for children and youth with serious behavioral health challenges. Conclusion While study findings reveal some uptake of system of care principles and practices among RTFs nationally, a greater emphasis on home- and community-based care, youth-guided and family-driven care, and cultural and linguistic competency is warranted. Federal and state programs addressing the mental health needs of children and youth increasingly are requiring provider attention to these issues supporting technical assistance and providing grant funding to make them the hallmarks of care. This leadership should guide RTFs seeking an evidencebased approach to sustaining and enhancing their mental health programs for children and youth. 10
11 Advancement of systems of care for this population requires that federal, state and local agencies engage RTF providers more effectively. RTFs, in turn, should reach out to entities that are engaged in system of care reform efforts in their states and communities to align and leverage their efforts. Continued dialogue is needed to build a common values base and practice model across the entire service continuum supporting the best possible outcomes for children and youth with serious behavioral health challenges and their families. About the Center for Health Care Strategies The Center for Health Care Strategies (CHCS) is a nonprofit health policy resource center dedicated to improving health care quality for low-income children and adults, people with chronic illnesses and disabilities, frail elders, and racially and ethnically diverse populations experiencing disparities in care. CHCS works with state and federal agencies, health plans, and providers to develop innovative programs that better serve Medicaid beneficiaries with complex and high-cost health care needs. For more information, visit Related CHCS Resources Through its Children in Managed Care program, the Center for Health Care Strategies (CHCS) works with state childserving agencies, health plans, and family- and youth-run organizations to improve the delivery of behavioral and physical health services and supports, with a focus on children served by multiple public systems. Visit to for more information on the following resources and initiatives: Improving Medicaid Managed Care for Youth with Serious Behavioral Health Needs: A Quality Improvement Toolkit - This toolkit details the experiences of a workgroup of nine Medicaid MCOs that collaborated to identify ways to improve care for youth with serious behavioral health needs. Medicaid Managed Care for Children in Child Welfare - This issue brief examines the complex physical and behavioral health care needs and associated costs for children in child welfare and outlines critical opportunities and challenges within Medicaid to better manage care for this high-risk, high-cost population. The Use of Psychotropic Medications for Children Involved in Child Welfare - This CHCS webinar presented evidence-based and promising practices related to the use of psychotropic medication among children involved in child welfare and the critical role of families as partners in care. A resource paper presenting these findings will be published this year. Improving Outcomes for Children Involved in Child Welfare - This national collaborative is working with nine managed care organizations and their child welfare partners to improve the delivery of physical and mental health care to children in child welfare. System of Care Approaches in Residential Treatment Facilities Serving Children with Serious Behavioral Health Needs 11
12 References 1 U.S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. Rockville, MD. 2 Ibid Note: Information about the initiative, including products and activities, can be found at 8 A. Drais-Perillo (2005). The Odyssey Project: A Descriptive and Prospective Study of Children and Youth in Residential Group Care and Therapeutic Foster Care, Child Welfare League of America. 9 Abt Associates, Inc. (2008). Characteristics of Residential Treatment for Children and Youth with Serious Emotional Disturbances. 10 Note: For more information about CAFAS, visit 11 R.C. Kessler, et al. Age of Onset of Mental Disorders: A Review of Recent Literature. Curr Opin Psychiatry, 2007 Jul;20(4): B.A. Stroul and R. Friedman (1986). A System of Care for Children & Youth with Severe Emotional Disturbances. CASSP Technical Assistance Center J. McMillen and L. Scott (2005). Use of Mental Health Services Among Older Youths in Foster Care. Psychiatric Services, 55: , American Psychiatric Association. 15 See the Children s Health Insurance Program Reauthorization Act at 16 S.B. Perlman and R.H. Dougherty (August 2006). State Behavioral Health Innovations: Disseminating Promising Practices. The Commonwealth Fund. 17 National Alliance on Mental Illness (June 2007). Mental Health Risk Factors Among GLBT Youth. 18 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (November 2002). Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders. 12
Center for Health Care Strategies, Inc. Utilization Management Considerations for Care Management Entities
CHCS Center for Health Care Strategies, Inc. Utilization Management Considerations for Care Management Entities Technical Assistance Brief June 2013 A number of states and regions have begun to demonstrateMore information
Residential Treatment Facility Proposed Regulations. OMHSAS Children s Advisory Committee January 6, 2011
Residential Treatment Facility Proposed Regulations OMHSAS Children s Advisory Committee January 6, 2011 Agenda Review of RTF regulation development process Overview of residential treatment facilitiesMore information
Mental Health Emergency Service Interventions for Children, Youth and Families
State of Rhode Island Department of Children, Youth and Families Mental Health Emergency Service Interventions for Children, Youth and Families Regulations for Certification May 16, 2012 I. GENERAL PROVISIONSMore information
Quick Guide. For Administrators. Based on TIP 52 Clinical Supervision and Professional Development of the Substance Abuse Counselor
Quick Guide For Administrators Based on TIP 52 Clinical Supervision and Professional Development of the Substance Abuse Counselor Contents Why a Quick Guide?...2 What Is a TIP?...3 Benefits and Rationale...4More information
Promoting the Well-Being of Children in Foster Care: The Role of Medicaid
Three Branch Institute on Child Social and Emotional Well-Being: Meeting for State Teams Promoting the Well-Being of Children in Foster Care: The Role of Medicaid Sheila A. Pires Human Service CollaborativeMore information
Using Home-Based Programs in Other States to Support a Medicaid Claim to Intensive Home-Based Services Under EPSDT
Using Home-Based Programs in Other States to Support a Medicaid Claim to Intensive Home-Based Services Under EPSDT December 2005 QA Center for Public Representation I. Introduction Because EPSDT requiresMore information
Intensive Customized Care Coordination Transaction
Transaction Code Detail Code Mod 1 Mod 2 Mod 3 Mod 4 Rate Code Communitybased wraparound Community-based wrap-around services H2022 HK services, monthly Unit Value 1 month Maximum Daily Units Initial 12More information
Strategies For Improving Access To Mental Health Services In SCHIP Programs
May 2006 Strategies For Improving Access To Mental Health Services In SCHIP Programs Prepared by: Jennifer May Children and adolescents experience substantial barriers to obtaining needed mental healthMore information
Outcomes for People on Allegheny County Community Treatment Teams
Allegheny HealthChoices, Inc. Winter 2010 Outcomes for People on Allegheny County Community Treatment Teams Community Treatment Teams (CTTs) in Allegheny County work with people who have some of the mostMore information
Evaluation Findings: Executive Summary Report to Congress 2009
Comprehensive Community Mental Health Services for Children and Their Families Program Evaluation Findings: Executive Summary Report to Congress 2009 SMA-##-####Summary The Comprehensive Community MentalMore information
The Louisiana Behavioral Health Partnership
The Louisiana Behavioral Health Partnership Transforming the lives of our youth Supporting adults in need Keeping families together Kathy Kliebert Deputy Secretary What is the Louisiana Behavioral HealthMore information
DEPT: Behavioral Health Division UNIT NO. 6300 FUND: General 0077. Budget Summary
2 Budget Summary Category 2014 Budget 2014 Actual 2015 Budget 2016 Budget 2016/2015 Variance Expenditures 1 Personnel Costs $71,051,105 $68,846,318 $63,170,918 $61,866,902 ($1,304,016) Operation CostsMore information
Report to the President and Congress Medicaid Home and Community-Based Alternatives to Psychiatric Residential Treatment Facilities Demonstration
Report to the President and Congress Medicaid Home and Community-Based Alternatives to Psychiatric Residential Treatment Facilities Demonstration As Required by the Deficit Reduction Act of 2005 (P.L.More information
Checklist for Juvenile Justice Agency Leaders and Managers
Checklist for Juvenile Justice Agency Leaders and Managers THE FOLLOWING CHECKLIST will help your agency conduct a detailed assessment of how current policy and practice align with what research has shownMore information
PSYCHIATRIC RESIDENTIAL TREATMENT PROGRAM MISSION STATEMENT Carson Valley Children s Aid is dedicated to the delivery of services to children, youth and families that ensure their safety, build on theirMore information
Wraparound Practitioner Care Coordination Certificate
Wraparound Practitioner Care Coordination Certificate Program for Care Coordinators and Supervisors The Institute for Innovation and Implementation University of Maryland, School of Social Work 525 W.More information
Best Principles for Integration of Child Psychiatry into the Pediatric Health Home
Best Principles for Integration of Child Psychiatry into the Pediatric Health Home Approved by AACAP Council June 2012 These guidelines were developed by: Richard Martini, M.D., co-chair, Committee onMore information
Texas Resilience and Recovery
Texas Resilience and Recovery Utilization Management Guidelines Child & Adolescent Services Texas Resilience and Recovery Utilization Management Guidelines: Child and Adolescent Services Effective SeptemberMore information
Substance Abuse and Mental Health Services Administration Reauthorization
Substance Abuse and Mental Health Services Administration Reauthorization 111 th Congress Introduction The American Psychological Association (APA) is the largest scientific and professional organizationMore information
Evidence Based Approaches to Addiction and Mental Illness Treatment for Adults
Evidence Based Practice Continuum Guidelines The Division of Behavioral Health strongly encourages behavioral health providers in Alaska to implement evidence based practices and effective program models.More information
H.R 2646 Summary and S. 1945 Comparison
H.R 2646 Summary and S. 1945 Comparison TITLE I ASSISTANT SECRETARY FOR MENTAL HEALTH AND SUBSTANCE USE DISORDERS It establishes an Office of the Assistant Secretary for Mental Health and Substance UseMore information
Reward for Quality Pilot Program
Reward for Quality Pilot Program TWO-YEAR OUTCOMES REPORT Magellan Behavioral Health of Pennsylvania Lehigh Valley Care Management Center Table of Contents Executive Summary... 2 Overview of Reward forMore information
PHILADELPHIA DEPARTMENT OF BEHAVIORAL HEALTH AND INTELLECTUAL disability SERVICES
PHILADELPHIA DEPARTMENT OF BEHAVIORAL HEALTH AND INTELLECTUAL disability SERVICES Program Description Guidelines I. Introduction A. Name of the Program Please give the name of the program you plan to operate.More information
Children, youth and families with co-occurring mental health and substance abuse issues are welcomed in every contact, and in every setting.
Practice Guidelines for the Identification and Treatment of Co-occurring Mental Health and Substance Abuse Issues In Children, Youth and Families June, 2008 This document is adapted from The Vermont PracticeMore information
Mental Health Nurses and their Employers See Enhanced Role for Nursing in Milwaukee County s Mental Health System
VOLUME 100, NUMBER 5 OCTOBER 2012 Mental Health Nurses and their Employers See Enhanced Role for Nursing in Milwaukee County s Mental Health System The Forum surveyed 120 mental health nurses and 34 employersMore information
OFFICE OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES BULLETIN ISSUE DATE: EFFECTIVE DATE: NUMBER: June 15, 2009 June 15, 2009 OMHSAS-09-04 SUBJECT: Best Practice Guidelines for Family Involvement withMore information
STATE OF OKLAHOMA THE RECOVERY COLLABORATIVE OF OKLAHOMA OKLAHOMA DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES OKLAHOMA HEALTH CARE AUTHORITY OKLAHOMA DEPARTMENT OF HUMAN SERVICES INTRODUCTIONMore information
TREATMENT MODALITIES. May, 2013
TREATMENT MODALITIES May, 2013 Treatment Modalities New York State Office of Alcoholism and Substance Abuse Services (NYS OASAS) regulates the addiction treatment modalities offered in New York State.More information
Agency of Human Services
Agency of Human Services Practice Guidelines for the Identification and Treatment of Co-occurring Mental Health and Substance Abuse Issues In Children, Youth and Families The Vermont Practice GuidelinesMore information
SENATE BILL No. 614 AMENDED IN ASSEMBLY JULY 16, 2015 AMENDED IN ASSEMBLY JULY 6, 2015 AMENDED IN SENATE APRIL 6, 2015
AMENDED IN ASSEMBLY JULY 16, 2015 AMENDED IN ASSEMBLY JULY 6, 2015 AMENDED IN SENATE APRIL 6, 2015 SENATE BILL No. 614 Introduced by Senator Leno (Coauthor: Senator Anderson) February 27, 2015 An act toMore information
Building Bridges: Innovations in Residential Treatment and in Integrating Residential and Community Services in Systems of Care
Building Bridges: Innovations in Residential Treatment and in Integrating Residential and Community Services in Systems of Care Marion County, Indiana Dr. Jim Dalton Vice President and COO Damar Services,More information
COMMUNITY SERVICES 238 HUMAN SERVICES. Mission Statement. Mandates. Expenditure Budget: $37,580,036 30.7% of Human Services
Mission Statement We are committed to improving the quality of life for people with or at risk of developing mental disabilities and substance abuse problems and to preventing the occurrences of theseMore information
ADDENDUM to. Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid
ADDENDUM to Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid Proposal to the Center for Medicare and Medicaid Innovation State Demonstration to Integrate CareMore information
What is CCS? Eligibility
What is CCS? Department of Health Services Division of Mental Health and Substance Abuse Services Bureau of Prevention, Treatment and Recovery Services Comprehensive Community Services (CCS) ComprehensiveMore information
Allocation of Outpatient Mental Health Services and Beds in State Hospitals. As Required By H.B. 3793, 83rd Legislature, Regular Session, 2013
Allocation of Outpatient Mental Health Services and Beds in State Hospitals As Required By H.B. 3793, 83rd Legislature, Regular Session, 2013 Department of State Health Services January 2015 - This pageMore information
Improving Service Delivery for High Need Medicaid Clients in Washington State Through Data Integration and Predictive Modeling
Improving Service Delivery for High Need Medicaid Clients in Washington State Through Data Integration and Predictive Modeling Getty Images, istock David Mancuso, PhD Analytics in the Social and HealthMore information
The following positions are available within URI. All interested applicants should forward an updated resume and cover letter via email to email@example.com. Include the position of interest in the emailMore information
Improving Service Delivery Through Administrative Data Integration and Analytics
Improving Service Delivery Through Administrative Data Integration and Analytics Getty Images David Mancuso, PhD October 2, 2015 1 Analytics in the Social and Health Service Environment Program costs areMore information
The Wraparound Process: An Overview of Implementation Essentials
This document was peer reviewed through the NWI. Supporting Wraparound Implementation: Chapter 5a.2 The Wraparound Process: An Overview of Implementation Essentials Eric Bruns, Co-Director, National WraparoundMore information
PARENT SUPPORT PROVIDER SELF- ASSESSMENT TRAINING CHECKLIST For use in calendar year 2013 National Federation of Families for Children s Mental Health 9605 Medical Center Drive Rockville Maryland 20850More information
Transitioning to The Health Home Model in PSH. Presented by Eric Morse, LISW-S, Chief Operating Officer
Transitioning to The Health Home Model in PSH Presented by Eric Morse, LISW-S, Chief Operating Officer Our Mission Reaching out to adults and children in Northeast Ohio to end homelessness, prevent suicide,More information
CPC Behavioral Healthcare 54 Years of Service 1960-2014
CPC Behavioral Healthcare 54 Years of Service 1960-2014 CPC Behavioral Healthcare was founded in 1960 as the Children s Psychiatric Center, the first mental health facility to offer outpatient servicesMore information
UTAH STATE UNIVERSITY. Professional School Guidance Counselor Education Program Mapping
UTAH STATE UNIVERSITY Professional School Guidance Counselor Education Program Mapping Course Key: PSY 6130 Evidence-Based Practice: School Intervention PSY 6240 Comprehensive School Counseling ProgramsMore information
Improving Service Delivery for Medicaid Clients Through Data Integration and Predictive Modeling
Improving Service Delivery for Medicaid Clients Through Data Integration and Predictive Modeling Getty Images, istock David Mancuso, PhD July 7, 2015 1 The Medicaid Environment Program costs are oftenMore information
Utah State University Professional School Counselor Education Program Learning Objectives (Adapted from the Standards for Utah School Counselor Education Programs and the Council for Accreditation of CounselingMore information
Service Coordination Core Training Module Component 1
Service Coordination Core Training Module Component 1 It is important to remember that the purpose of this training program is to provide general information about case management services for eligibleMore information
Procedure/ Revenue Code. Billing NPI Required. Rendering NPI Required. Service/Revenue Code Description. Yes No No
Procedure/ Revenue Code Service/Revenue Code Description Billing NPI Rendering NPI Attending/ Admitting NPI 0100 Inpatient Services Yes No Yes 0114 Room & Board - private psychiatric Yes No Yes 0124 RoomMore information
Redesigning the Publicly-Funded Mental Health System in Texas
Redesigning the Publicly-Funded Mental Health System in Texas Access to care when services are needed Choice in health plans for consumers and providers Integration of care at the plan and provider levelMore information
FRAMEWORK FOR PRACTICE CASEWORKER COMPETENCE. in a specific environmental setting, and at a particular developmental stage. 2
be safely reunited with his or her family, CPS must implement the alternative permanency plan. FRAMEWORK FOR PRACTICE This section explains how practitioners apply the philosophical tenets described aboveMore information
Complete Program Listing
Complete Program Listing Mental Health (MH) Services Division Adult Mental Health Outpatient Clinics - Provide outpatient mental health services to individuals 18 years and older who live with severe andMore information
Contra Costa County System of Care Planning and Policy Council Memorandum of Understanding
Contra Costa County System of Care Planning and Policy Council Memorandum of Understanding This Memorandum of Understanding is created for the purpose of forming a multiagency collaborative called theMore information
CROSS-SYSTEM APPROACHES THAT PROMOTE CHILD WELL-BEING: STATE EXAMPLES FROM NORTH CAROLINA, PENNSYLVANIA, AND COLORADO By Susan Foosness, William Shutt, and Richard Whipple November 2014 Introduction: ChildMore information
White Paper. School Psychologists: Qualified Health Professionals Providing Child and Adolescent Mental and Behavioral Health Services
White Paper School Psychologists: Qualified Health Professionals Providing Child and Adolescent Mental and Behavioral Health Services School psychologists are uniquely trained to deliver high quality mentalMore information
THE ALLENDALE ASSOCIATION. Pre-Doctoral Psychology Diagnostic Externship Information Packet 2015-2016
THE ALLENDALE ASSOCIATION Pre-Doctoral Psychology Diagnostic Externship Information Packet 2015-2016 INTRODUCTION TO ALLENDALE The Allendale Association is a private, not-for-profit organization locatedMore information
Summary of the Final Medicaid Redesign Team (MRT) Report A Plan to Transform The Empire State s Medicaid Program
Summary of the Final Medicaid Redesign Team (MRT) Report A Plan to Transform The Empire State s Medicaid Program May 2012 This document summarizes the key points contained in the MRT final report, A PlanMore information
Alabama Autism Task Force Preliminary Recommendations
Alabama Autism Task Force Preliminary Recommendations Having reviewed the findings to date from the Alabama Autism Collaborative Group (AACG), The Alabama Autism Task Force proposes the following changesMore information
CSI Training Supplement Evidence-Based Practices (EBPs) and Service Strategies (SSs) (S-25.0)
CSI Training Supplement Evidence-Based Practices (EBPs) and Service Strategies (SSs) (S-25.0) July 14, 2006 Note: This training supplement is intended to serve as a tool for counties to use in order toMore information
Behavioral Health Rehabilitation Services: Brief Treatment Model
Behavioral Health Rehabilitation Services: Brief Treatment Model Presented by Allegheny HealthChoices, Inc. 444 Liberty Avenue, Pittsburgh, PA 15222 Phone: 412/325-1100 Fax 412/325-1111 April 2006 AHCIMore information
MERCY MARICOPA INTEGRATED CARE Job list*
MERCY MARICOPA INTEGRATED CARE Job list* Position Integrated Health Care Development Officer Chief Clinical Officer Arizona-licensed clinical practitioner Children's Medical Arizona-licensed physician,More information
I. Policy and Governance Advocacy
I. Policy and Governance Advocacy Description These efforts include advocating for legislative or policy changes in government and institutions, with a goal of convincing as many systems as possible thatMore information
DEPARTMENT OF SERVICES FOR CHILDREN, YOUTH AND THEIR FAMILIES DIVISION OF CHILD MENTAL HEALTH SERVICES PROGRAM DESCRIPTIONS OVERVIEW The Division of Child Mental Health Services provides both mental healthMore information
STATE OF NEVADA Department of Administration Division of Human Resource Management CLASS SPECIFICATION
STATE OF NEVADA Department of Administration Division of Human Resource Management CLASS SPECIFICATION TITLE GRADE EEO-4 CODE MENTAL HEALTH COUNSELOR V 43* B 10.135 MENTAL HEALTH COUNSELOR IV 41* B 10.137More information
Integrating Behavioral Health and Primary Health Care: Development, Maintenance, and Sustainability Cici Conti Schoenberger, LCSW, CAS Behavioral
Integrating Behavioral Health and Primary Health Care: Development, Maintenance, and Sustainability Cici Conti Schoenberger, LCSW, CAS Behavioral Health Provider Sunshine Community Health Center Why Integrate?More information
Juvenile and Domestic Relations District Court
LOB #190: LONG-TERM RESIDENTIAL CARE Purpose The Long-Term Residential Care (LTRC) Line of Business incorporates three programs: Boys Probation House (BPH) Foundations Transitional Living Program (TLP)More information
Connecticut Children s Behavioral Health Plan. Executive Summary
Connecticut Children s Behavioral Health Plan Prepared pursuant to Public Act 13-178 And Submitted to Connecticut General Assembly October 1, 2014 Submitted by: Joette Katz, Commissioner Connecticut DepartmentMore information
Orange County is located between Los Angeles and San Diego
This document was peer reviewed through the NWI. Supporting Wraparound Implementation: Chapter 5d.3 The Wraparound Orange County Model Denise Churchill, Program Manager Orange County Children and FamilyMore information
CHAPTER 535 HEALTH HOMES. Background... 2. Policy... 2. 535.1 Member Eligibility and Enrollment... 2. 535.2 Health Home Required Functions...
TABLE OF CONTENTS SECTION PAGE NUMBER Background... 2 Policy... 2 535.1 Member Eligibility and Enrollment... 2 535.2 Health Home Required Functions... 3 535.3 Health Home Coordination Role... 4 535.4 HealthMore information
I. Introduction and Intent As communities implement strategies to end homelessness, they need to be able to provide effective housing and services options for people experiencing homelessness who haveMore information
Overview. AACP Positions on Access to Psychiatric and Psychopharmacologic Services in Underserved Areas 1
AMERICAN ASSOCIATION OF COMMUNITY PSYCHIATRISTS POSITION PAPER ON ENSURING ACCESS TO RECOVERY ORIENTED SAFETY NET PSYCHIATRIC SERVICES IN UNDERSERVED AND ECONOMICALLY DISTRESSED COMMUNITIES Overview TheMore information
Professional Treatment Services in Facility-Based Crisis Program Children and Adolescents
Professional Treatment Services in Facility-Based Crisis Program Children and Adolescents Medicaid and North Carolina Health Choice (NCHC) Billable Service WORKING DRAFT Revision Date: September 11, 2014More information
MRT WAIVER AMENDMENT PROGRAMS TO BE IMPLEMENTED THROUGH STATE PLAN AMENDMENT AND MANAGED CARE CONTRACTS As discussed with CMS, implementation of the MRT Waiver Amendment reinvestment programs will be achievedMore information
I. General Instructions
Contra Costa Behavioral Health Services Request for Proposals Mental Health Services Act (MHSA) Mental Health Recovery Centers October 16, 2013 I. General Instructions Contra Costa Behavioral Health ServicesMore information
Nursing and Health Reform
Nursing and Health Reform The Patient Protection and Affordable Care Act (PPACA) was signed into law by President Obama on March 23, 2010. This law will enact sweeping changes to almost every facet ofMore information
Optum By United Behavioral Health. 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines
Optum By United Behavioral Health 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines Statewide Inpatient Psychiatric Program Services (SIPP) Statewide Inpatient PsychiatricMore information
Patient Protection and Affordable Care Act [PL 111-148] with Amendments from 2010 Reconciliation Act [PL 111-152] Direct-Care Workforce
DIRECT-CARE WORKFORCE AND LONG-TERM CARE PROVISIONS AS ENACTED IN PATIENT PROTECTION AND AFFORDABLE CARE ACT AND HEALTH CARE AND EDUCATION RECONCILIATION ACT OF 2010 Key Provisions Direct-Care WorkforceMore information
December, 2009. Salary, Education, Benefits, and Job Descriptions of Nurses, Teachers, and Social Workers: A Comparative Analysis
December, 2009 Salary, Education, Benefits, and Job Descriptions of Nurses, Teachers, and Social Workers: A Comparative Analysis Contents Introduction 3 Problem Statement 3 Social Work within the TexasMore information
Targeted Case Management Services
Targeted Case Management Services 2013 Acronyms and Abbreviations AHCA Agency for Health Care Administration MMA Magellan Medicaid Administration CBC Community Based Care CBH Community Behavioral HealthMore information
Testimony to Senate Ways and Means Social Services Subcommittee. February 3, 2015
Association of Community Mental Health Centers of Kansas, Inc. 534 S. Kansas, Suite 330, Topeka, KS 66603 Telephone (785) 234-4773 Fax (785) 234-3189 Website: www.acmhck.org Kyle Kessler Executive DirectorMore information
How to Use. The Treatment of Depression in Older Adults Evidence-Based Practices KITs. The Treatment of Depression in Older Adults
How to Use The Treatment of Depression in Older Adults Evidence-Based Practices KITs The Treatment of Depression in Older Adults How to Use The Treatment of Depression in Older Adults Evidence-Based PracticesMore information
Iowa Medicaid Integrated Health Home Provider Agreement General Terms
Iowa Medicaid Integrated Health Home Provider Agreement General Terms This Agreement is between the state of Iowa, Department of Human Services, (the Department ) and the Provider (the Provider ). TheMore information
October 15, 2010. Re: National Health Care Quality Strategy and Plan. Dear Dr. Wilson,
October 15, 2010 Dr. Nancy Wilson, R.N., M.D., M.P.H. Senior Advisor to the Director Agency for Healthcare Research and Quality (AHRQ) 540 Gaither Road Room 3216 Rockville, MD 20850 Re: National HealthMore information
Guiding Principles for Quality Services and Supports
VIII. Background Quality Management The OMHSAS Quality Management program ensures public accountability and continuous quality improvement of OMHSAS programs and services. The OMHSAS Quality ManagementMore information
July 15, 2015. Dear April Leonhard:
July 15, 2015 April Leonhard Department of Human Services Office of Long Term Living, Bureau of Policy and Regulatory Management P.O. Box 8025 Harrisburg, PA 17105-8025 Dear April Leonhard: Thank you forMore information
Mode & Service Function Information
Mode & Service Function Information 20 S/D Mode 05 = 24-Hour Services SD/MC Mode 05 = Residential/PHF SD/MC Mode 07 = General Hospital SD/MC Mode 08 = Psych Hospital: Age < 21 SD/MC Mode 09 = Psych Hospital:More information
Florida Medicaid. Mental Health Targeted Case Management Handbook. Agency for Health Care Administration
Florida Medicaid Mental Health Targeted Case Management Handbook Agency for Health Care Administration JEB BUSH, GOVERNOR ALAN LEVINE, SECRETARY June 7, 2006 Dear Medicaid Provider: Enclosed please findMore information
Health Disparities in H.R. 3590 (Merged Senate Bill)
Health Disparities in H.R. 3590 (Merged Senate Bill) Definitions: Health disparity population is defined in the bill as defined in Section 485E (Sec. 931) Current Law: a population is a health disparityMore information
ALCOHOL, DRUG ADDICTION, AND MENTAL HEALTH BOARDS OF OHIO The Value of Ohio s Alcohol, Drug Addiction, and Mental Health Boards Providing hope and helping local communities thrive ++--------- LOCAL NEEDSMore information
Keeping Families Together. A guide for families to understand intensive treatment options for children with mental illnesses
Keeping Families Together A guide for families to understand intensive treatment options for children with mental illnesses CONTENTS Introduction... 1 Children with Mental Illnesses... 3 Emotional DisturbanceMore information
Behavioral Health Division
Milwaukee County Department of Health & Human Services Behavioral Health Division Héctor Colón, MS, OT, DHHS Director Patricia Schroeder, RN, MSN, MBA, FAAN, Administrator Jim Kubicek, LCSW, Deputy AdministratorMore information
Telecare Corporation A GUIDE TO OUR SERVICES. Our Background. Our Clients
Our Background is one of the nation s largest providers of services and supports to individuals with serious mental illness (SMI). Our Clients Telecare s clients are typically adults (18-55), older adultsMore information
Fairfax-Falls Church Community Services Board
106-15-Alcohol and Drug Youth Residential Services Fund/Agency: 106 Fairfax-Falls Church Community Services Board Personnel Services $2,121,873 Operating Expenses $675,691 Recovered Costs $0 Capital EquipmentMore information
UNDER DEVELOPMENT CLASS TITLE: Social Work Support Technician (currently Youth Residential Worker 1)
OCCUPATIONAL GROUP: Social Services CLASS FAMILY: Social Work CLASS FAMILY DESCRIPTION: This family of positions includes those whose purpose is to provide social services to various populations, includingMore information
DCF 2014 Inventory and Needs Assessment for New Jersey Behavioral Health
DCF 2014 Inventory and Needs Assessment for New Jersey Behavioral Health A Report by Children s System of Care Allison Blake, Ph.D., L.S.W. Commissioner Pursuant to New Jersey Statute 30:4-177.63, thisMore information
Fact Sheet on School Mental Health Services
Fact Sheet on School Mental Health Services School-aged children and youth have a range of mental health disorders: A 1999 Surgeon General report on mental health cites the following prevalence estimates:More information
City of Los Angeles, 2003-2008 Consolidated Plan
, 2003-2008 Consolidated Plan D. Other Special Needs Supportive and Housing Services The Mayor has identified residents with special needs as a top priority for the Consolidated Plan and Annual ActionMore information
Permanency Process to Ensure Quality and Timely Services are delivered to Children and Families
Youthville is one of the largest, nonprofit child welfare agencies in Kansas, specializing in foster care, adoption, counseling, and psychiatric residential facility treatment (PRTF). The agency has moreMore information
SERVICE AREA AND OVERVIEW EXECUTIVE SUMMARY Anderson-Oconee-Pickens Mental Health Center (AOP), established in 1962, serves the following counties: Anderson, Oconee and Pickens. Its catchment area hasMore information
Regional Family Justice Center Network Concept Paper June 2007
Regional Family Justice Center Network Concept Paper June 2007 Regional Family Justice Center Network Family violence is an extremely complex issue which manifests itself in varying dynamics within familiesMore information
Psychiatric Rehabilitation Services
DEFINITION Psychiatric or Psychosocial Rehabilitation Services provide skill building, peer support, and other supports and services to help adults with serious and persistent mental illness reduce symptoms,More information
CLINICAL SERVICES TREATMENT TRACKS. Drug and Alcohol Treatment. Drug and Alcohol Treatment
ABRAXAS OHIO For over 20 years Abraxas Ohio has been serving youth and families through partnerships with juvenile court systems and child caring agencies throughout the state of Ohio. The Abraxas Group,More information


text:
Cheverly hotels and motels with swimming pools that are perfect for a family are listed below. Search for cheap and discount hotel rates at hotels with a pool in or near Cheverly, MD for your upcoming individual or family vacation. We list the best pool equipped, kid friendly Cheverly Maryland hotel and motel rooms for children. Review the list of Cheverly hotels with indoor or outdoor pools below to find the perfect lodging for you and your kids.Planning group travel? Get Cheverly MD Group Hotel Rates
How should we direct your call?

subset: commoncrawl


text:
To bring smile in their face who ever will come in my way...
If you love an image (whether it's yours or someone else's) and want to make sure others get a chance to see it, you can "feature" it by choosing the "Spotlight" button.
When an image is Spotlighted, it receives enhanced visibility in premium spots throughout the site. Spotlighted images are rotated through these higher-visibility positions to ensure the best opportunity for the images to be seen by JPG users.
If you see a great photo that would make a perfect entry for one of our Shoot Out photo contests but it was uploaded by another user, now you can enter that photo in the contest and, if it wins, you get to share in the contest winnings.
Like a photo editor, if you've got an eye for great work, find it and submit it to a contest. If it wins, since you staked the entry fee, you'll take home part of the prize (the rest, of course, goes to the member who shot the image).
Collections are a JPG+ feature. You must be a JPG+ member to create new collections and to add photos to collections.
Sign up for JPG+ to start using collections now!
Photo license: © All rights reserved
I took this photo during my trip to a Hill station in southern part of India.These four boys (probably orphans) requested me to take their photo and as soon as I clicked and showed them they felt very happy as if they are seeing their photo for the first time and the next moment all of them vanished,even I could n't take their address to post the photos.The whole day I was looking for them so that I can give a printed copy and I will feel proud to see that instant smile on their face.I am still searching for them ..............
5 responses
Andrea Petersen gave props (3 Jan 2013):
This is a great portrait of these young boys who each carry their own expression ...and I hope you do see them again
Leslie Hunziker gave props (3 Jan 2013):
they look so proud and serious in this. beautifully captured.
Tomma Henckel gave props (4 Jan 2013):
Beautiful picture - too bad you could not get their contact information to send them a copy.
Donald Garrett gave props (10 Jan 2013):
A noble resolution and great portrait!
ROCIO GUILLEN gave props (10 Jan 2013):
What a beautiful resolution! Great portrait!
Also by rashmi a
Please Login or Sign Up
Login or Sign Up
Need contest credits? Get 'em here!
Payments are processed by PayPal and you will be automatically forwarded to PayPal to complete your transaction. It may take a few minutes after you complete your transaction for you contest credits to update. We will send an email to your registered email address once we have received a successful transaction from PayPal and updated you credits.
Select a Shoot Out contest credit package below.


text:
Property Location
With a stay at Innside Berlin, you'll be centrally located in Berlin, convenient to O2 World and Alexanderplatz. This 4-star hotel is close to Checkpoint Charlie Museum and Brandenburg Gate.
Make yourself at home in one of the 133 guestrooms featuring minibars and LCD televisions. Wireless Internet access (surcharge) keeps you connected, and satellite programming is available for your entertainment. Private bathrooms with bathtubs or showers feature complimentary toiletries and hair dryers. Conveniences include desks and complimentary newspapers, and housekeeping is provided daily.
Rec, Spa, Premium Amenities
Don't miss out on recreational opportunities including a sauna and a fitness center. Additional amenities include wireless Internet access (surcharge), concierge services, and tour/ticket assistance.
Satisfy your appetite at the hotel's restaurant, which serves breakfast and dinner, or stay in and take advantage of room service (during limited hours). Quench your thirst with your favorite drink at a bar/lounge.
Business, Other Amenities
Featured amenities include complimentary newspapers in the lobby, dry cleaning/laundry services, and a 24-hour front desk. Planning an event in Berlin? This hotel has facilities measuring 700 square feet (65 square meters), including meeting rooms.
Are you affiliated with Innside Premium Hotels Berlin? Apply to the Hotel WiFi Connect program to take control of your account, improve your hotel's confidence score and ranking.
© 2013-2016 Hotel WiFi Test Inc.


text:
These images should fit perfectly as your Facebook profile pictures. Choose your favorite color logo below, right click on the image ( command click on your Mac), save to you computer and then upload as your profile picture.
We would love to hear how you use these images. So please share your story with us. Email email@example.com
If you are looking for the larger cover images, check out our Facebook Covers page.


text:
'I'm just part of a chain,' Raphaël Pitoun tells me when I ask about the man behind the successful US equity fund that is Stryx America.
The Seilern Investment Management CIO's self-deprecation could almost fool you into forgetting that he is the man to beat when it comes to investing in US companies, as he outpaces virtually all other fund managers in this hotly contested field.
The Citywire AAA-rated manager is gaining recognition among professional fund buyers, particularly for his US equity fund, which he manages alongside the Stryx World Growth fund.
When I ask about his best and worst investment calls, he immediately identifies one of the best – Estée Lauder – but struggles when it comes to his shortcomings. 'There are a lot. I need to pick the right one,' he jokes.
The A-team
Outside the office, Pitoun's calm, carefully judged nature has helped him find the perfect outlet for his interest in politics, acting as an impartial moderator on discussion panels.
Likewise, in fund management, Pitoun puts his success down to the fund's harmonious investment team. He works closely with company founder and chairman, Peter Seilern-Aspang; the manager of the European fund, Tassilo Seilern-Aspang; and research analysts Michael Faherty, Corentin Massin and Fernando Leon.
Tight and tidy is a good way to describe both the team and its strategy, as the six investment experts narrow the global investable universe of all Seilern funds down to a basket of just 60 companies.
Targeting a very small niche of the equity market, the team works on an exclusionary basis to create a concentrated set of firms with very little turnover. It is this exhaustive and determined approach to creating an investment universe that has generated the bulk of the alpha for the funds, Pitoun says.
'It is a very stable universe of stocks. You can see it as a kind of oil tanker that is moving very slowly.
'If you consider this room as the capital market, what we invest in is the size of a shoe box. We are not value and we are not growth. We really want to focus on those exceptional companies and leave the rest aside.'
Kicking the tyres
Although Pitoun does consider valuations, what really counts is the quality, growth and predictability of the business, he explains. Even when a company ticks all the boxes, it can still take up to a year of intensive investigation before it is added to the investable universe. This belt-and-braces approach to research is undertaken in-house by the investment team.
The research helps to keep the portfolio's turnover low – something that is most obvious when comparing the latest presentation for the fund with one from a decade ago, Pitoun adds.
It was Pitoun's dedication to thorough research that first forged a bond between him and Peter Seilern-Aspang four years ago, when the two first met.
Pitoun has been an equity and research specialist for more than 20 years, starting on the sell-side, before moving to the buy-side – all the while maintaining a fascination for what makes a company exceptional over the long term. At Seilern, research continues to be central to Pitoun's work, and the final portfolio construction is only a small part of what he does, he says.
Of the 60 companies in the global universe, only 32 are American, from which the manager builds a portfolio of around 20 stocks.
The Stryx America fund runs a similar strategy and process to the global and European funds in its range, Pitoun says, targeting the best companies in the world in terms of quality and growth.
Fashion foe
It is important not to be lured by the waves of fashion or short-term hype in stock picking, says Pitoun, and to focus instead on the predictability of a company's returns and business practices.
This naturally excludes certain sectors where the manager doesn't find quality companies. One such sector is banking, where the level of transparency and earnings growth are both too low for Pitoun, while volatility is too high.
Similarly, Pitoun doesn't invest in commodity stocks – including oil and gas, steel and mining, and iron ore – because the cost base is too variable.
He also steers clear of sectors or industries that don't provide enough growth, such as utilities, telecoms and real estate.
On the other hand, the industries he favours are those where scale and innovation are important, where the barriers to entry are sustainable and where capital is not a competitive advantage. 'As capital is very cheap today, it's a very weak advantage,' he says.
He offers the commodities sector as an obvious example of this: with more capital you can try to extract more oil. The same goes for the hotel business, where with capital you can build more hotels, or the airline industry, where cash can buy more jets. 'We want to have companies whose competitive advantages are sustainable and not driven by capital.'
Advantages, meanwhile, can include the quality of a distribution network or the market configuration, such as an oligopolistic environment.
The largest holding in the fund at 8.3% as of April, Mastercard, is a strong example of this as it has a number of competitive advantages that make it exceptional, Pitoun says.
First, its distribution network would be very difficult to replicate, because a competitor would need to talk to hundreds of thousands of retailers and get them to accept the payment method. Second, the brand is associated with safety, which is very important and hard to replicate, especially when talking about transferring money.
The global group also has a reputation for innovation, which is why it is no mystery that both Visa and Mastercard have a good market share offline. However, the market share online is actually much greater, Pitoun says. The two groups have managed to deploy the right products online to capture e-commerce.
No Fang-ks
'We are definitely not a FANG fund,' Pitoun exlpains when asked about the fund's largest sector exposure, which is a 35% weighting to information technology.
The portfolio does not include Amazon, Netflix or Apple, because none of them fulfil the criteria the manager is looking for.
'Take Amazon for example,' he says. 'Most of its profits come from Amazon Web Services Cloud business and very little from e-commerce, so we don't know where the margins are going to land. The predictability is not high enough.'
The exception to that rule is Alphabet, which is the second-largest holding in the portfolio at 7.1%. It is more predictable, Pitoun says, because it relies on the digital advertising market, where there are plenty of projections and where you can predict operating margins.
Alarm bells
Pitoun is not after dividends, though. In fact, an increase in dividends often acts as a red flag, as it could mean that the company doesn't have any potential to reinvest cash profitably, he explains.
'We pay a lot of attention to monitoring the payouts of companies. If that increases, most of the time it's a bad sign.'
This can be seen in consumer staples, a space that the manager is reluctant to invest in as there has been an increase in the number of expensive and risky acquisitions. Companies have started to leverage their balance sheets, adding more debt to give cash to shareholders.
This is counterintuitive, Pitoun says, arguing that it is incredible that companies choose to add more debt to their balance sheets when they have little predictability in their business models.
Fizzling out
Large food companies such as Nestlé, Unilever, Pepsi Cola and Colgate have fallen out of favour since the team carried out a deep dive on the sub-sector. These firms and others like them used to make up between 15% and 20% of the portfolio, but Pitoun has since concluded that the space was at risk of going ex-growth.
'In the past, these companies had been delivering a mediocre level of growth but with a very high level of predictability, so it helped the predictability of the portfolio as a whole. But then we realised after doing this investigation that the algorithm of the growth they were living on for decades was actually fading and that the predictability of this growth was being questioned.
'They were growing more and more through pricy acquisitions, so we became a bit more sceptical and lowered massively the exposure to consumer staples over the past two years.'
Following the investigation, Pitoun sold the Stryx America fund's exposure to Pepsi and other consumer staples, reducing the exposure to the sector to approximately 8%.
A steady hand
Riding out volatility is one of Pitoun's strongest skills, and a skill that was put to the test during February's market correction.
Pitoun's fund weathered the majority of the market risk, with the total return dropping by just 1.8 percentage points from 60% in January to 58.2% in March. The average manager's return fell by 7.7 percentage points over the same period of time.
When asked how he protects his portfolio from volatility, he says it's all in the stock selection, finding companies with a long track record, strong corporate governance and alignment between shareholders and managers, and critically a healthy balance sheet.
'The strength of the balance sheet helps to mitigate the volatility of the stock market,' he says.
'The companies we invest in are listed in the equity market but they don't need the stock market in terms of reputation and raising new assets, so they are listed for random reasons. We take advantage to buy them for the long term.'
As a result, Pitoun and his investment team's extensive research and conviction-based approach have propelled the fund into the upper echelons of the US equity sector. The fund is certainly one to watch for the future.
This article originally appeared in the May issue of Citywire Switzerland.


text:
Investigators with the Canada Revenue Agency raided an address in West Vancouver Wednesday in connection with an investigation into possible tax evasion connected to the Panama Papers.
CRA investigators went into the West Vancouver address with a search warrant Wednesday morning, assisted by the West Vancouver Police.
The West Vancouver raid was one of three carried out simultaneously by about 30 CRA investigators on Wednesday. Other searches were carried out in Calgary and Toronto.
The CRA did not release the address where the search in West Vancouver was conducted or any names associated with it.
The agency said in a statement the searches were connected to a criminal investigation into offshore tax evasion related to the data leak from the Panamanian law firm Mossack Fonseca, made public in the Panama Papers.
"The CRA's investigation identified a series of transactions involving foreign corporations and several transfers through offshore bank accounts
... read more at: http://www.burnabynow.com/news/panama-papers-probe-sees-cra-raid-in-west-vancouver-1.23177031


text:
I need help getting a good "hook" for this (http://sandbox.scp-wiki.net/jekeled-s-sandbox) draft (it's the first entry in the tab).
This isn't a specific hook, but I think you need to explore why they commit suicide. Some well placed details on what drives them to suicide might be just the hook you need.
Allright, I'll work on ways to put that in.
Hmm…I'm not sure if I should go for an interview log, or something else…
Yeah. I'm not sure myself. There are several ways you could do this.
an interview with a dying victim or survivor, couple of hints in the description, even a few choice experiments in a log. I don't know which way would be best but I would lean towards a note in an experiment or a couple of hints in the description. An Interview seems a bit too obvious, and I think the power of this SCP is going to come in the realizationby the reader of why these animals and people would commit suicide. If its too clear it will lose its effectiveness.
Just thoughts though.
It's a bridge that kills dogs and makes people near it sad.
Not too bad. The "why they jump" bit was good. But I still don't know it'll stand with that. But I can't think of anything better, so I'd start with that.
Ok, how about just straight up adding hooks? Once something dies from jumping off the bridge, long chains with hooks on the end get dropped out a small window, and haul up the body (might take a few tries). Nobody can find a room that goes with the window, or it's otherwise inaccessible.
Allright, I added a few things. Let's see if this helps it.


text:
San Luis Obispo Criminal Defense Attorney
The Best San Luis Obispo Criminal Defense Attorneys
At Central Coast Criminal Defense our team of San Luis Obispo criminal defense attorneys provide high-quality, aggressive, personalized, representation you can afford. It's that simple. Our experienced team of criminal attorneys are here to help you, and we have the experience in the San Luis Obispo court to do so. We are in the San Luis Obispo courthouse virtually every single day representing clients facing Domestic Violence charges, DUI's, Drug Charges, Theft Charges, and more. It is important that you hire an attorney who is a good match for you. Come meet us. If you are facing criminal charges in San Luis Obispo County, you should at least meet with us. We are happy to review your case at no obligation. We are confident that you will feel very comfortable, having met us. We know we can help you. Would you like to Chat by Text During Business Hours? Click the red button on the bottom right of your screen to text-chat with an Attorney.
You Need A San Luis Obispo Criminal Defense Attorney Who is Willing to Fight For You
No one is more willing to go to bat for their clients than we are. We fight hard because we are not intimidated by the District Attorney, and we genuinely care about our clients. We fight to keep our clients out of jail. Once we can avoid jail our focus shifts to minimizing all of the potential negative consequences. We have a very good track record of helping our San Luis Obispo clients avoid jail.
You Need An Experienced San Luis Obispo Criminal Defense Attorney
We are experienced, local, criminal defense attorneys. Attorney Cody Christiansen is a former Public Defender. He is now excited to be working privately where he has a smaller number of clients. This allows Cody to give everyone of his cases the serious focus it deserves. Since leaving the office of the public defender Cody has gained valuable experience defending clients in San Luis Obispo that he can use to help you. We know how to fight and win cases in the San Luis Obispo courthouse. We know the law, and we know how things work locally. Knowing the law and knowing the local practices are two keys in getting our clients the results they deserve.
We Make Great Criminal Defense Affordable
The bottom line is that we are here to help our clients. We know that we are not helping our clients if we over-charge them. We keep our fees affordable for our clients. We are happy to arrange a payment plan that fits within your budget. Our attorneys are genuinely passionate about defending their clients and keeping them out of jail. When you do what you love, you don't need to overcharge people. Our fees are low and our payment arrangements are flexible. You can great criminal defense. Call us today.
Meet Our Attorneys
Kit Westbrook
Billy Redell
SLO Criminal Defense Topics of Interest :
Drunk In Public / Disorderly Conduct
Domestic Violence Charges
Proposition 47
Petty Theft Defense
Criminal Record Expungement
The DMV Hearing
Can DUI's Be Successfully Defended?
Felony DUI's
Drug Charge Defense
Free Consultation. Call Us. (805) 621-7181
We know that people who are charged with crimes experience a great deal of anxiety. We can help. Rather than wonder about the strength of your case, consult with us immediately. It's free to consult with one of our experienced criminal lawyers. We can put you at ease. Call us now for a free consultation either by phone or in-person.
Consult with any other attorney you would like, but do yourself a huge favor and consult with us before you hire anyone else. Our consultations are free. We are confident that if you meet with us, you will see that we are the criminal defense attorneys you want fighting for you.
We Offer High Quality Criminal Defense
A great attorney knows how to go over a case with a fine tooth comb. We pay careful attention to the little deals that are the key to you defense. We catch the small details, less careful attorneys miss. Quality is the key. We take the time on every single case to get it right. We will leave no stone un-turned as we fight to keep you out of jail and help you avoid an unfair criminal conviction.
Facing Domestic Violence Charges? See Our New Domestic Violence Videos Below
Domestic Violence Basics PC 243(e)(1)
Domestic Violence PC 273.5
Visit Us!
Central Coast Criminal Defense
867 Pacific St. #220
San Luis Obispo, Ca 93041
(805) 621-7181


text:
Apple is expected to launch its sixth generation iPhone around September or October of this year, the device is expected to be called the iPhone 5, we have previously heard that NFC may be included in Apple's next generation iPhone.
Apple recently announced PassBook, which is a new mobile wallet that will launch with iOS6, Apple will probably launch the iPhone 5 at the same time as iOS 6.
Now according to a recent report from 9 to 5 Mac, two new iPhone prototypes have been discovered which have NFC, which would mean that the next iPhone would probably come with NFC.
We have also heard that Apple's iPhone 5 is expected to feature a larger 4 inch display, and we have seen some parts which support this rumor that are apparently from Apple's next iPhone.
Source GizmodoFiled Under: Apple, Apple iPhone, Technology News, Top News


text:
Manchester United winger Memphis Depay is Lyon's "number one priority" this month.
But manager Jose Mourinho says that the Dutchman will not be leaving Old Trafford unless the French side come up with a reasonable offer.
Depay, 22, has been underwhelming since arriving at United in the summer of 2015 for £25million.
He has made just one start in all competitions since Mourinho's arrival and Lyon have emerged as a leading candidate for the United winger's signature.
Talks have begun between the clubs and coach Bruno Genesio confirmed that the French club are keen to bring the Holland international to the Parc Olympique Lyonnais.
"Things are progressing, we keep on working," Genesio was quoted as saying on www.olweb.fr when asked about this month's transfer plans.
"It takes time, discussions...because recruiting a player now is not easy. I trust the president to get things done quickly.
"I have put a priority on Memphis Depay.
"He is a powerful player who scores goals and is good at set-pieces. Rachid (Ghezzal) has left for the African Nations Cup and Memphis knows how to play out wide.
"He is a young player with great international experience and a lot of potential. This is my number one priority.
"I'm a fan of this player, he has an interesting profile for us, especially as we risk losing Rachid at the end of the season.
"But there are several things to consider, including the price."
United boss Mourinho has confirmed that the fee for Depay is a sticking point - one which the Red Devils will not waver on, even if it means he remains at Old Trafford.
"The update is that the offer we had is far from being reasonable for us," he said.
"So in this moment, he is our player and if in the end of the month nothing happens, he is one more option for us"
Morgan Schneiderlin left United for Everton on Thursday, moving for an initial £20million fee that is expected to reach £24million due to add-ons.