Expanding the Role of the Hub Clinics

opportunities for DCFS management to work with CSWs that have a history of cases that are not referred to or result in missed appointments at Hub Clinics. Additionally, DCFS and DHS should establish clear roles and responsibilities for temporary CSWs or PHNs that will be placed at the Hub Clinics to facilitate following up on missed appoint- ments and referrals to special medical and mental health services. FINDINGS – DCFS ACCOUNTABILITY 3.1. In FY 2010-11, 22.9 percent, or 6,822 out of 29,743 scheduled appointments at Hub Clinics were missed across all seven Hub Clinics. This contributes to an ineffi- cient use of resources at Hub Clinics. Opportunities are missed to schedule new DCFS referrals, increasing the risk of youth not receiving needed medical and/or mental health diagnoses, care and services. 3.2. An analysis of missed appointments for Forensic Evaluations scheduled at LAC+USC revealed that more than half of the no-shows did not have an appoint- ment rescheduled within that same month. 3.3. A majority of the referrals for Forensic Evaluations are for non-detained youth. Timely Forensic Evaluations for non-detained youth at Hub Clinics with medical providers that have specialized training in detecting abuse and neglect could help to reduce the risk of further abuse and, possibly, the number of child deaths among open DCFS cases in which the youth is placed in-home with their alleged abusers. 3.4. More systematic referral and access to outpatient mental health services for non- detained youth and their parents for a period of six months after the non-detained youth first enters the child welfare system may help prevent further abuse and ne- glect for this population. 3.5. Hub Clinics lack sufficient resources to follow up on no-shows and reschedule ap- pointments, as well as referrals to medical specialists and/or mental health ser- vices. Follow up should be conducted by DCFS staff, as consistent with existing DCFS policies and procedures. 3.6. Some DCFS CSWs lack an understanding of department policies and procedures regarding Hub Clinic referrals and follow up on missed appointments. 3.7. A system of management accountability is being implemented by DCFS. Though it is an improvement over current practices, this system could be further improved to 284 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT EXPANDING HUB CLINICS – 3. DCFS ACCOUNTABILITY include concrete processes for addressing problem cases and communication fail- ures among CSWs. 3.8. While funding has been approved to hire and temporarily co-locate Public Health Nurses and Children’s Social Workers at the Hub Clinics, roles and responsibilities could be more clearly defined and directed toward utilizing these new positions to follow up on missed appointments and referrals to specialized medical and mental health services.

MENTAL HEALTH SERVICES THROUGH DMH Multidisciplinary Assessment Teams (MATs) As part of the County of Los Angeles’ settlement agreement from the Katie A. lawsuit,10 the Department of Children and Family Services (DCFS) has made it a policy that all newly detained youth are required to receive a mental health screening or assessment and appropriate linkage to services in a timely manner. To accomplish this, DCFS and the Department of Mental Health (DMH) have collaborated to expand their Multidiscipli- nary Assessment Team (MAT) Assessment Program to all Service Planning Areas. However, this assessment occurs independent of the DCFS detention process, which includes the Initial Medical Exam and mental health screening at the Hub Clinics. Once detained by DCFS as a result of a court order, a youth is referred by staff for a multidisciplinary assessment, generally conducted by a DMH-contracted community- based organization called a MAT Provider. This assessment is intended to provide a comprehensive understanding of the complicated issues that families face when they first enter the foster care system and to enable DCFS Children’s Social Workers (CSWs) to determine more effectively 1) the appropriate placement for the youth; 2) services needed by the youth and their families; and 3) early diagnosis and intervention of critical medical, dental and mental health issues. The MAT Provider gathers information from various sources in the following key areas with regard to the youth and their family: 1) level of engagement; 2) family’s functioning; 3) family’s strengths and needs; 4) child’s functioning, including interpersonal, physical health, mental health, developmental, educational, and vocational functioning, if appli- cable; 5) child’s strengths and needs; 6) current placement; and 7) alternate place- ments, if applicable. For MAT sessions, interviews are conducted with the youth’s parents and/or caregivers and parent-child interactions are observed. A team is assembled to evaluate the find- ings from the interviews and plan for needed services. This team generally includes a mix of individuals involved with the case including: the caregiver; family members; the child, if appropriate; Children’s Social Worker (CSW); Public Health Nurse (PHN) and others concerned with the case. MAT Assessments and Hub Clinics Linkage between the MAT Assessments and Hub Clinics is very limited. The most direct linkage is through the use of the medical report from the Initial Medical Examinations at the Hub Clinics, but these reports are not always available or used in MAT Assess- 10 In July 2002, the “Katie A., et al. v. Diana Bontá" class-action lawsuit was filed against the State of California and the County of Los Angeles on behalf of five named plaintiff foster children and a class of children and young adults who are in the custody of DCFS, or have been referred to or are subject to being referred to DCFS. In lieu of mone- tary compensation, the Katie A. plaintiffs requested that the State and County improve upon its delivery of mental health services to children and families. http://www.lacdcfs.org/katieA/docs/Settlement%20Agreement.pdf 286 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT EXPANDING HUB CLINICS – 4. MENTAL HEALTH SERVICES ments. For instance, youth referred for a MAT Assessment can obtain a medical report from either a Hub Clinic or a community provider. Although detained youth are mandat- ed by DCFS to obtain an Initial Medical Examination at one of the Hub Clinics, a sepa- rate DCFS policy on MAT Assessments contradicts this requirement by allowing the as- sessments to include medical exams from community providers. Secondly, per DCFS and DMH policy, the MAT Assessment must be completed within 30-45 days after acceptance of a referral. However, according to DMH management, though DCFS requires Initial Medical Examinations to be completed at the Hub Clinics within 30 days of initial placement, the actual timing of the Initial Medical Examinations does not always coincide with the 30-45 day requirement for the completion of the MAT Assessment. As discussed in Section 3 of this report, 22.9 percent of the referrals to the Hub Clinics in FY 2010-11 resulted in missed appointments. Because the findings of the MAT Assessment must be presented to the Court, the medical exam is often provided by a community provider. As previously mentioned, a MAT team consisting of various stakeholders and service providers is assembled to evaluate the detained youth’s condition and service needs. According to the Memorandum of Understanding between DCFS and DHS, one of the goals of the Hub Clinics is to “improve coordination and child health care outcomes.” Though their input could be valuable, particularly for youth with Special Health Care Needs,11 except for rare occasions, Hub Clinic staff do not participate in the MAT team meetings. Without the participation of medical Hub Clinic staff and PHNs in MAT team meetings, an opportunity is lost to improve coordination and integration of medical and other care in service plans. PHNs could serve as the critical link between the Hub Clinics and the MAT Assess- ments because of their understanding of medical issues and their responsibility to coun- sel CSWs on medical issues related to their cases. With the approval of additional Title IV-E Waiver funds for hiring PHNs to be co-located at the Hub Clinics, DCFS and DHS should include attending MAT Assessments as one of the prioritized responsibilities of these PHNs. Mental Health Screenings and Ongoing Mental Health Services An additional shared goal of the MAT Assessments conducted by MAT Providers and the Initial Medical Exams conducted at the Hub Clinics is to perform mental health screenings, identify mental health needs, and ensure linkage to additional services. Though there are shared goals in identifying mental health needs, the MAT Providers and the Hub Clinics were provided different mental health screening tools by DMH. In particular, the MAT Providers use a more in-depth screening tool. According to DMH management, the use of different mental health screening tools at the Hub Clinics is dic- 11 Special Health Care Needs is defined by DCFS Procedural Guide 0600-505.10 as: 1) a condition that can rapidly deteriorate resulting in permanent injury or death, or 2) a medical condition that requires specialized in-home health care. 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 287 EXPANDING HUB CLINICS – 4. MENTAL HEALTH SERVICES tated by the varying levels of expertise of the screeners at the Hubs. Inconsistent train- ing and the use of a different screening tool could potentially lead to: 1) inability to iden- tify mental health services that are needed or 2) referrals for mental health services that are not needed. Although DMH-contracted MAT Providers are able to provide MAT Assessments as well as ongoing mental health services, there is limited linkage between the MAT Providers and Hub Clinics for ongoing mental health services. There are 50 organizations in the County that contract with DMH to be MAT Providers and provide MAT Assessments and ongoing mental health services. In contrast, there are seven Hub Clinic locations and only two are affiliated with organizations that have contracts with DMH to be MAT Providers and ongoing mental health service providers: LAC+USC and Children’s Hos- pital. The East San Gabriel Valley Satellite Hub Clinic has access to mental health ser- vice providers through its affiliation with LAC+USC. Data on mental health screenings at the Hub Clinics in FY 2010-11 illustrates that as high as 80 percent of youth screened at the clinics have a positive result, indicating a need for additional mental health services. Without strong linkages to the DMH system, these youth are in danger of not receiving needed mental health services, violating the intent of the Katie A. Settlement. Table 4-1 below shows the number of mental health screenings and results across all Hub Clinics in FY 2010-11. Table 4-1. Number of Mental Health Screenings and Results (FY 2010-11) ESGV H-UCLA LAC+USC MLK OV-UCLA HD CHLA TOTAL # Screenings 1,184 1,713 6,244 1,537 1,051 1,238 466 13,433 # Positive Results 482 859 3,253 322 844 802 369 6,931 % Positive 41% 50% 52% 21% 80% 65% 79% 52% Source: DHS records System of Integration LAC+USC and Children’s Hospital are the only Hub Clinics that are able to provide mental health services simultaneously or immediately after an Initial Medical Examina- tion because they are both affiliated with larger organizations that contain separate mental health service divisions that are also DMH contractors. (The Violence Interven- tion Project is the parent non-profit organization for the LAC+USC Hub Clinic and the Children’s Hospital Hub Clinic is part of Children’s Hospital LA.) The East San Gabriel Valley Satellite has access to mental health providers through LAC+USC. The new Children’s Medical Village at LAC+USC, which is slated to begin operations in 2012, will also provide mental health services to its patients as part of its comprehensive, multi- disciplinary approach. Two other Hub Clinics are poised to provide more direct linkages to mental health ser- vices. Though they are not officially affiliated, the Martin Luther King, Jr. Hub Clinic is located in the same building as SHIELDS, a DMH contractor and MAT Provider, while the Harbor-UCLA Hub Clinic is located a few bungalows away from Children’s Institute, 288 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT