The Quality of Care for TennCare Children and Adolescents
with Serious Emotional Disorder
Article prepared by Craig Anne Heflinger Ph.D.- Principal Investigator
with Andrea Flowers - Data Disseminator

As part of the IMPACT Study,¹ an in-depth review assessed the quality of care received by TennCare children with serious emotional disorder (SED). Quality of care was assessed for the period of time between the child's entry into the IMPACT Study and six months later when this sub-study was conducted. All of the 92 children (ages 5 to 17) who participated in this sub-study met criteria for SED when they entered the study, and 75% continued to meet the SED criteria six months later. This sub-study assessed the quality of care provided by the behavioral health system under TennCare Partners. A case review process² was used to rate the quality of care provided using information from children, parent/caregivers, behavioral health care providers, teachers, and other sources. The rating system was based on the ideal principles of care set forth in the Children and Adolescent Service System Program (CASSP) including the following: ³

·        Children with emotional disturbances should have access to a comprehensive array of services that address the child’s needs. 

·        Children with emotional disturbances should receive individualized services in accordance with the unique needs and potentials of each child and guided by an individualized service plan.

·        The families of children with emotional disturbances should be full participants in all aspects of the planning and delivery of services.

·        Children with emotional disturbances should be provided with case management or similar mechanisms to ensure that multiple services are delivered in a coordinated and therapeutic manner and that they can move through the system of services in accordance with their changing needs.

Figure 1: Summary of System Ratings

Figure 1 summarizes the overall rating of the system. The service system received acceptable ratings for care provided to approximately 50% to 75% of the children on any particular indicator. Family and Child Participation in Treatment Planning and Comprehensive Assessment were the most consistently acceptable.

Case reviewers observed many instances where behavioral health services were delivered in a manner that helped children with SED feel better, function more adequately in daily settings and progress toward becoming mature and responsible adults. Examples of the following best practices of the TennCare behavioral health care system were found:

·        Comprehensive assessment and ongoing treatment planning;

·        Family and child participation in treatment planning;

·        Services individualized to needs of child and family;

·        School-based services with child/family participation in treatment planning; and

·        TennCare coverage of services.

            The case reviews revealed instances of exemplary behavioral health service delivery where providers took a strengths-based, “big picture” and long-term view of the child and family in careful assessment and planning. These providers were creative and flexible and wanted the child to develop a positive sense of self-worth and gain skills necessary to live a fulfilling and productive life. This resulted in these particular families gaining maximum benefits from behavioral health services.

Ideally, treatment for children with SED should address emotional, behavioral, and physical well-being in all spheres of life. Treatment plans should address physical health, safety and educational needs. Substance abuse problems should also be addressed, especially for this sample in which over one-third (41%) of youth ages 12 to 18 reported ever using drugs or alcohol. The system performed relatively well in the areas of physical health and education. Most of the children (93%) appeared to receive acceptable physical health care services under TennCare, and 82% received educational services that met their needs at an acceptable level. 

However, problems in service system performance were also observed. Taken as a whole, less than one-half (44%) of the children in the study received the behavioral health services that targeted the needs of the individual child and family, and were of sufficient intensity and quality to produce desired results (see Figure 1). Service coordination and long-term planning seemed to be the most serious challenge to the system. Although the TennCare benefit package was designed to offer a comprehensive array of services, the implementation of the TennCare program for these children was problematic at times. In many cases, needs went unrecognized or ignored, TennCare benefits were lacking, services were unavailable, fragmented or misdirected, or treatment planning was incomplete or short-sighted. Often, parents/caregivers were told that their children needed certain services but that TennCare would not pay for them. Despite the fact that all the children in the study met criteria for SED at the beginning of the study, 27% received no behavioral health services in the following six months. Indeed, 25% of the children in this study were found to have worsening emotional and behavioral problems during the six-month assessment period.

A child’s well-being is connected with the well-being of his/her parent(s)/caregiver(s) and families. In many cases, caregivers for this group of children were under tremendous strain. Seventy-three percent of parents/caregivers reported being worried about their child's future and almost half (49%) reported feeling tired and strained. In addition, roughly one-quarter of the parents/caregivers were struggling with their own mental illness or substance abuse problems. The study found that there was an insufficient support system in place for caregivers of this group of children.

In summary, the primary service system challenges included:

·        Inadequate TennCare coverage of services and providers dropping out of the program

·        Lack of referral in transition between treatment modalities

·        Inadequate long-range planning

·        Inadequate family/caregiver supports

·        Lack of coordination between service systems.

Although some best practices were found, the overall system faces ongoing challenges that need to be addressed for the sake of these children. The challenges need to be examined at the local and state level, and initiatives to address them should include attention to staff training, program administration and funding, and policy issues. State and local policy makers, program administrators, behavioral and physical health service providers, family members and child advocates should work together to address these needs. By strengthening the foundation of the current system, treatment for Tennessee’s youth with SED can be improved.

¹ This article is based on one of several reports from the IMPACT Study, conducted by Vanderbilt University's Center for Mental Health Policy in conjunction with Tennessee Voices for Children, the Tennessee Commission on Children and Youth, and Mississippi Families as Allies. The IMPACT Study focused on mental health and substance abuse issues of school-aged Medicaid children and adolescents in Tennessee and Mississippi, and was funded by the United States Department of Health & Human Services (USDHHS) Substance Abuse and Mental Health Services Administration (SAMHSA) as part of a national study to examine the impact of Medicaid managed care on vulnerable populations.  To download the report this article is based upon, please go to:  http://www.vanderbilt.edu/VIPPS/CMHP/pdfs/TNQuality.pdf. 

2 Based on service testing, see 2 Groves, I. D., & Foster, R. E.  (1995).  Service Testing:  Assessing the quality and outcomes of systems of care performance through interaction with individual children served.  Presentation at the 8th Annual Research Conference, A System of Care for Children’s Mental Health: Expanding the Research Base, Tampa, FL.

3 Extracted from Stroul, B., & Friedman, R. (1986, revised edition).  A System of Care for Severely Emotionally Disturbed Children and Youth.  Washington, DC: CASSP Technical Assistance Center.

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