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Maximizing Opportunities to Increase Child and Family Well Being Through

Innovative Funding Approaches

Sheila A. Pires

Human Service Collaborative

Washington, DC

Because Minds Matter: Collaborating to Strengthen Psychotropic Medication Management for Children and Youth in Foster Care

August 27-28, 2012Washington, DC

Effectiveness Research(Barbara Burns’ Research at Duke University)

• Most evidence of efficacy: Intensive case management, in-home services, therapeutic foster care

• Less evidence (because not much research done): Crisis services, respite, mentoring, family education and support

• Least evidence (and lots of research): Inpatient, residential treatment, therapeutic group home

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.2

Examples of What You Don’t See Listed as Evidence-Based Practice

(though they may be standard practice)

• Traditional office-based “talk” therapy• Residential Treatment• Group Homes• Day Treatment_______________________________________________Examples of Potentially Harmful Programs and Effective Alternatives in Dodge, K., Dishion, T., & Lansford, J. (2006). “Deviant Peer Influences in Intervention and Public Policy for Youth,” Social Policy Report, Vol. XX, No. 1, January 2006. Youth Today: The Newspaper on Youth Work, Vol. 15, No. 7.

Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C. 3

Broad, Flexible Service ArrayExample: Dawn Project Services & Supports

Behavioral Health•Behavior management•Crisis intervention•Day treatment•Evaluation•Family assessment•Family preservation•Family therapy•Group therapy•Individual therapy•Parenting/family skills training•Substance abuse therapy, individual and group•Special therapy

Placement•Acute hospitalization•Foster care•Therapeutic foster care•Group home care•Relative placement•Residential treatment•Shelter care•Crisis residential•Supported independent living

Psychiatric•Assessment•Medication follow-up/psychiatric review•Nursing services

Mentor•Community case management/case aide•Clinical mentor•Educational mentor•Life coach/independent living skills mentor•Parent and family mentor•Recreational/social mentor•Supported work environment•Tutor•Community supervision

Respite•Crisis respite•Planned respite•Residential respite

Service Coordination•Case management•Service coordination•Intensive case management

Other•Camp•Team meeting•Consultation with other professionals•Guardian ad litem•Transportation•Interpretive services

Discretionary•Activities•Automobile repair•Childcare/supervision•Clothing•Educational expenses•Furnishings/appliances•Housing (rent, security deposits)•Medical•Monitoring equipment•Paid roommate•Supplies/groceries•Utilities•Incentive money

2005 CHIOCES, Inc., Indianapolis, IN

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Types of Medicaid Services in Systems of Care

• Assessment and diagnosis

• Outpatient psychotherapy

• Medical management

• Home-based services

• Day treatment/partial hospitalization

• Crisis services – mobile & residential

• Behavioral aide services

• Behavioral management skills training

• Therapeutic foster care

• Therapeutic group homes

• Targeted Case Management

• Inpatient hospital services• Case management services• School-based services• Respite services• Wraparound • Family peer support/education• Youth peer support• Transportation• Mental health consultation• Early intervention and prevention services• Supported independent living• Residential treatment centers• Telehealth

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Examples of Sources of Funding for Children/ Youth

Pires, S. (1995). Examples of sources of behavioral health funding for children & families in the public sector. Washington, DC: Human Service Collaborative.

Medicaid• Medicaid Inpatient• Medicaid Outpatient• Medicaid

Rehabilitation Services Option

• Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT)

• Targeted Case Management

• Medicaid Waivers• TEFRA Option• ACA options

Substance Abuse• SA General Revenue• SA Medicaid Match• SA Block Grant

Juvenile Justice• JJ General Revenue• JJ Medicaid Match• JJ Federal Grants

Mental Health• MH General Revenue• MH Medicaid Match• MH Block Grant

Child Welfare• CW General Revenue• CW Medicaid Match• IV-E (Foster Care and

Adoption Assistance)• IV-B (Child Welfare

Services)• Family

Preservation/Family Support

Education• ED General Revenue• ED Medicaid Match• Student Services

Other• TANF• Children’s Medical

Services/Title V– Maternal and Child Health

• Mental Retardation/ Developmental Disabilities

• Title XXI-State Children’s Health Insurance Program (SCHIP)

• Vocational Rehabilitation

• Supplemental Security Income (SSI)

• Local Funds

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FIRST PRINCIPLE: System Design Drives Financing

Adapted from Friedman, M. (1995). Financing strategies to support improved outcomes for children. Washington, DC: Center for the Study of Social Policy.

REDIRECTIONUsing the money we already haveThe cost of doing nothingShifting funds from treatment to earlyintervention and preventionMoving across fiscal years

REFINANCINGGenerating new money by increasing federal claimsThe commitment to reinvest funds for families and childrenFoster Care and Adoption Assistance (Title IV-E)Medicaid (Title XIX)

RAISING OTHER REVENUE TO SUPPORT FAMILIES AND CHILDREN

DonationsSpecial taxes and taxing districts for childrenFees & third party collectionsTrust funds

FINANCING STRUCTURES THAT SUPPORT GOALS

Seamless services: Financial claiming invisible to families Funding pools: Breaking the lock of agency ownership of fundsFlexible Dollars: Removing the barriers to meeting the unique needs of familiesIncentives: Rewarding good practice

Financing Strategies and Structures

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Redirection

Where are you spending resources onhigh costs and/or poor outcomes?

Residential Treatment?Group Homes?Detention?Hospital admissions/re-admissions?Too long stays in therapeutic foster care?Inappropriate psychotropic drug use?“Cookie-cutter” psychiatric and psychologicalevaluations?

Implications for How RTCs are Utilized

• Movement away from “placement” orientation and long lengths of stay

• Residential as part of an integrated continuum, connected to community

• Shared decision making with families/youth and other providers and agencies

• Individualized treatment approaches through a child and family team process

• Trauma-informed care

For more information, go to Building Bridges Initiative:www.buildingbridges4youth.org

Data Trends #127, February 2006,University of South Florida. 9

The Cost of Doing Nothing

If Milwaukee County had done nothing: the $18m. spent by child welfare ten years ago would be $48m. today

Project Bloom “Cost of Failure Study” Early childhood services at an average cost per child of $987/year save $5,693/year in special education

If New Jersey had done nothing: it would have spent $30m more in inpatient psychiatric hospitalization over the last three years

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The Cost of Doing Nothing:Racial & Ethnic Disparities/Disproportionality

“…youths of color were less likely to receive outpatient therapy…..and more likely to receive residential services.” (1)

“The study finds greater use of residential treatmentcenters by black persons and Hispanic persons thatis attributable in part to (public sector) managed care” (2)

1. McMillen, J., Scott, L.et. al. Use of Mental Health Services Among Older Youths In Foster Care. 2004. Psychiatric Services 55:811-817. American Psychiatric Association

2. Snowden, L., Cuellar, E. & Libby, A. Minority Youth in Foster Care: Managed Care and Access to Mental Health Treatment. 2003. Med Care. 41(2): 264-74). University of California Berkley

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Strategic Financing Analysis

1. Identify state and local agencies that spend on youth/families at risk

How much? What kind of $?

2. Identify resources that are untapped or under-utilized (e.g., Medicaid)

3. Identify utilization patterns and expenditures

Consider high cost/poor outcome

Pires, S. 2006. Human Service Collaborative. Washington, D.C.

4. Identify disparities and disproportionality in access to service/supports

What are the strategies to address?

5. Identify the funding structures that will best support the system design

Braided, blended, risk-based, purchasing collaborative???

6. Identify short and long term financing strategiesFederal revenue maximization; re-direction from

restrictive levels of care; waiver; performance incentives; legislative proposal; taxpayer referendum

Strategic Financing Analysis

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System of Care

Child Welfare

Alternative to out-of-home care high costs/poor outcomes

Juvenile Justice

Alternative to detention-high cost/poor outcomes

Medicaid

Alternative to IP/ER/PRTF; multiple psychotropic meds

Education

Alternative to out-of-schoolplacements, high special ed costs

Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

Aligning Incentives Across Agencies

UMDNJ Training & TA Institute

Department of Children and FamiliesDivision of Child Behavioral Health Services

Dept. of Human ServicesMedicaid Division

BH, CW, MA $$ - Single Payer

Provider Network

Contracted Systems Administrator- PerformCare

•1-800 number•Screening•Utilization management•Outcomes tracking

Any licensed DCF provider

Family peer support,education and advocacyYouth movement

Lead non profit agencies managing children with seriouschallenges, multi-system involvement

New Jersey

Care Management Organizations - CMOs

Family SupportOrganizations

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Louisiana

Children’s System of Care (CSoC) Governing Body

Medicaid, Behavioral Health and Child Welfare

dollars

1915 b and c waivers

Statewide Management

Organization (ASO)

Regional Care Management Organizations

Family Support Organizations

Provider Network

Magellan

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Care Management Entity FunctionsAt the Service Level: Child and family team facilitation using high quality

Wraparound practice model Screening, assessment, clinical oversight Intensive care coordination Care monitoring and review Peer support partners Access to mobile crisis supports

At the Administrative Level: Information management – real time data; web-based IT Provider network recruitment and management (including

natural supports) Utilization management Continuous quality improvement; outcomes monitoring Training Pires, S. 2010. Human Service Collaborative

Affordable Care Act Opportunities and Challenges

Medicaid Re-Design

Renewed interest in various waivers/options

• 1115, 1915b, 1915i, Money Follows thePerson, health homes

Renewed interest in managed care, includingfor populations with high use/cost (e.g., chronicconditions, foster care, SSI)

I. Customizing Medicaid Managed Care forChildren/Youth in Child Welfare and At Risk

Requirements for:

Incorporation of State and federal requirements for child welfarepopulation, e.g. PH and BH screens within certain timeframe,monitoring of psychotropic meds (requirement for all children)Risk-adjusted rate for children in child welfare and childrenwith serious behavioral health challengesSpecial liaison for child welfare-involved children,children enrolled in Care Management Entities, youth transitioningHire/contract with family and youth organizations to serve as family and youth advocates and peer supportsIncentives to require out-of-office careSpecific performance measures related to children in child welfare Reinvestment back into child home and community services

Pires, S. 2012.Washington DC: Human Service Collaborative

II. Customizing Medicaid Managed Care forChildren/Youth in Child Welfare and At Risk

Requirements for:

EPSDT inclusion of behavioral health screens and linkageto BH services when indicatedBroad BH benefit, inclusive of in-home, respite, family andyouth peer support, mobile response and stabilization, behavioralmanagement consultation, therapeutic foster care, telebehavioral healthProvider network requirements to include: providers trained in child welfare population issues, EBPs, trauma-informed care; racially/ethnically diverse providers; inclusion of families/youth asproviders/advocatesEnhanced rates for providers trained in EBPs and trauma-informed careTimely provider payments

Pires, S. 2012. Washington DC: Human Service Collaborative

III. Customizing Medicaid Managed Care forChildren/Youth in Child Welfare and At Risk

Requirements for:

No “fail first” policies regarding access to service type or psychotropic med typeSpecific “pass-through” case rate for Care Management Entityor wraparound team approach for children with most complexchallengesUse of standardized tools for screening, and determination ofservice intensity neededPrior authorization parameters that enable “ready access” toservices (e.g., first 12 visits do not require prior auth)Prior authorization parameters that allow wraparound plan ofcare to drive medical necessity (with outlier management)

Pires, S. 2012. Washington DC: Human Service Collaborative

IV. Customizing Medicaid Managed Care forChildren/Youth in Child Welfare and At Risk

Requirements for:

Quality review process that involves families and youthwith lived experience on quality review teams and requiresinput from child welfare systemData tracking requirements to include: service useand expenditures of children in foster care, including psychotropic meds – stratifiable by age, gender, race/ethnicity, aid category, region, diagnosis, service type, medication typeEngagement in quality improvement initiatives involvingchildren’s behavioral health and children in child welfareFocus groups and satisfaction surveys of youth and familiesinvolved in child welfare and of child welfare workers

Pires, S. 2012. Washington DC: Human Service Collaborative

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Summary of Financing Characteristicsof Systems of Care for Children/Youth and Families

in Child Welfare and At Risk

Maximize Medicaid (e.g., flexible Rehab Option)Blend, braid or intentionally coordinate funding streamsacross systemsRe-direct spending from high cost and/or poor outcomeservices to effective practicesManage dollars through managed care arrangements thatare tied to values and goalsRisk adjust payment for complex populations of children(e.g., risk-adjusted capitation rates to MCOs; case rates toproviders)Finance locus of accountability – e.g., care management entitiesfor most complex, cross-systemFinance family and youth partnerships at policy, managementand service levels Finance training, capacity building, quality and outcomes monitoring

Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

For further information, contact:

Sheila A. PiresHuman Service Collaborativesapires@aol.com