By Jeremy Loudenback

The Katie A. v. Bonta lawsuits leveled California and Los Angeles County with the charge that every county in the state provide adequate mental health services for some of its most vulnerable children.

The state settled the case in 2011. Los Angeles County settled a separate lawsuit in 2003, suggesting that it would be ahead of the state’s 57 other counties in providing better mental health services for what is known as the Katie A. Subclass (read part one for a breakdown of which children are eligible to be counted in the subclass).

In Los Angeles, the largest single child welfare system in the country, Katie A. observers note significant overall advancements, particularly in screening, with a lot of work left to do regarding treatment. 

Thanks to a new focus on supporting mental health services at medical centers across the county, Los Angeles is poised to continue its progress on coordinating these services for children in its massive child-welfare system. But lingering questions remain about its ability to consistently provide services to children who require specialized mental health services.

The number of Los Angeles foster youth receiving mental health treatment has greatly increased under the settlement. About three percent of youth with open cases with the Department of Children and Family Services (DCFS) received mental health services in 2003, according to the county’s Department of Mental Health (DMH). The percentage has ranged from 60 to 70 percent in recent years.

Officials say that the county’s progress in making mental health services accessible to foster youth has been significant thanks to a new universal screening process administered to children and youth who are suspected victims of maltreatment.

“Previously they might just have slipped through the system without a lot of attention to their mental health needs,” said DMH District Chief Gregory Lecklitner. “We are providing a much more significant assessment process for those kids and also getting those kids and their caregivers into services.”

Those results have earned plaudits from plaintiffs in the settlements. Attorney Antoinette Dozier of the Western Center on Law and Poverty is quick to praise the work of DMH and DCFS, especially when it comes to the co-location of DMH staff in DCFS offices over the past decade.

“Los Angeles County far and away has made more progress than any of the other counties out there,” said Dozier, who has monitored Los Angeles County’s implementation of the Katie A. settlements. “The county [has] done a great job in expanding mental health services for kids with mental health needs, including the kids with intensive mental health needs.”

Among the bright spots is the assessment and treatment center operated by the Violence Intervention Program (VIP) Community Mental Health Center, created to connect some of Los Angeles County’s most vulnerable foster youth to services.

VIP provides supportive services to children who have experienced abuse or neglect. Its Children’s Welcome Center, housed at the Los Angeles County-USC Medical Center, offers temporary shelter and meals to children in the 24 hours after they have been removed from their parents’ custody.

An agreement approved by the Los Angeles County Board of Supervisors in September will allow VIP to expand to a vacant structure close to other VIP buildings in the medical center. In exchange for a free 10-year lease, VIP is paying about $1 million to renovate the structure to serve transition-age foster youths.

The new building is slated to open in six months.

VIP Executive Director Astrid Heppenstall Heger estimates that more than 75 percent of all children who currently come through the door at the VIP’s Welcome Center have mental health issues of some sort.

“Many…have never actually been adequately assessed for what their strengths [are] or what kind of diagnosis they have,” said Heger.  “Right now, the kids we see need a lot of care coordination and case management.”

She anticipates that the new building will serve between 200 to 300 teenagers each month by providing them with temporary housing and connecting them with independent living resources and education programs in addition to mental health services available at the nearby VIP Community Mental Health Center.

Observers note unevenness in treatment patterns, caused by challenges in supply and quality.

Mandated by the Katie A. settlements, Intensive Care Coordination and Intensive Home-Based Services are two approaches to providing high-quality wraparound services to children with serious mental health needs. Intensive Care Coordination is a way to help children and families locate and coordinate appropriate mental health services and supports across many different providers or government agencies.

Intensive Home-Based Services are coordinated clinical services provided in a child’s home and community, with the goal of establishing permanency and avoiding placement in congregate-care settings.

According to the court progress reports for the state case, two-thirds of all Intensive Home-Based Services in the state are taking place in Los Angeles County. Nearly three-quarters of the time spent on Intensive Care Coordination occurs in Los Angeles.

This does not correspond with what observers say is happening in the county.

“We’ve been told by children and mental health service providers that there is a wait list in some areas of the county,” Dozier said. “There does need to be an increase [in] mental health services and a look at whether there are enough services to serve all the children in need.”

“We need to fund more intensive services for kids,” Lecklitner said. “That’s the focus right now of our discussions with the attorneys on the panel right now. How can we provide funding for those additional services that we need?”

Dozier believes DMH lacks the resources needed to ensure county mental-health providers are capable of providing the higher-intensity services.

“In Los Angeles there are about 10,000 providers. DMH has about three coaches working to try to monitor, train, and coach those 10,000 providers in L.A. County,” Dozier said. “That’s a huge barrier in terms of getting the change in practice out into the community so that all of the children who need the services can take advantage.”

Another lingering issue is the disappointing number of children in the county’s Therapeutic Foster Care (TFC). Both Katie A. settlements have mandated the increased use of TFC to handle the tremendous number of children who demonstrate a high need for intensive services in Los Angeles County.

According to the terms of both settlements, Los Angeles is committed to making 300 TFC homes available.

“We haven’t been able to get much over 100 at any point in time in the last 10 years,” Lecklitner said.

In fairness, most counties in the state have not incorporated TFC yet because it has not been approved as an allowable expense under Medicaid. That leaves the county on the hook to pay for the intervention – approximately $5,300 per month for one child – without tapping into Early Periodic Screening, Diagnosis and Treatment, a Medicaid program that guarantees mental health services for low-income and foster youths.

The state has sought an amendment to its Medicaid plan to include TFC, and federal approval could come by January 2015, according to Department of Finance spokesman H.D. Palmer.

Lecklitner said that supply is also an issue with TFC, not just cost. “The largest challenge for us here in Los Angeles is recruiting and retaining foster parents. In general we have a significant shortage of foster homes for DCFS kids, but a lot of folks who might otherwise be interested in becoming a foster parent are reluctant to take on some of these more difficult children.”

Unlike the state, which will relinquish oversight of the requirement of the Katie A. lawsuit in December, Los Angeles has to prove it is ready to move out from under the oversight of its court-appointed advisory panel.

Before Los Angeles County exits the 2003 settlement, it must make strides to improve its application of the core practice model (CPM). The CPM is a family and youth-centered approach to effectively delivering intensive mental health services like Intensive Care Coordination and Intensive Home-Based Services.

In order to measure its progress on putting into practice the CPM approach, Los Angeles County is employing the Quality Service Review (QSR) tool to measure its implementation of the CPM at nine DCFS offices. The offices have been self-reporting QSR scores that track how well the CPM model is being implemented.

Until Los Angeles County meets certain court-mandated standards for its QSR scores, it will remain under the oversight of a special Katie A. advisory panel. “QSR scores are important because they will tell us whether or not we’re doing the core practice model, but they’re also benchmarks for the county’s exit of the lawsuit,” Lecklitner said.

Whether or not Los Angeles County makes enough progress on its QSR scores to exit the settlement soon, the county will move forward this year with several mandates on the mental health of foster children. The county has agreed to adopt the full slate of reform recommendations made by its Blue Ribbon Commission on Child Protection, which requires the following in terms of mental health:

• Assessment of the strengths and weaknesses of each “Medical Hub”, and a guarantee that all children entering placement under age one be screened at a Medical Hub.
• Mandatory home-visit services and physician services should be available to all children under age one who are seen at the Hub.
• Development of a computerized, real-time system to identify available and appropriate placements based on the specific needs of the child.
• Prioritization of non-pharmacological interventions for children.

As Katie A. implementation heads toward an uncertain future, there’s still more work to be done to ensure the county never sees another Katie A. in its system.

Jeremy Loudenback is a reporter for The Chronicle of Social Change. Editor-in-chief John Kelly also contributed to this story.