Building Systems of Care for Children and Youth with Behavioral Health Challenges

Sheila A. PiresSenior Partner, Human Service Collaborative

Core Partner, Technical Assistance Network for Children’s Behavioral HealthSenior Consultant, Child Health Quality Programs

Center for Health Care Strategies

Illinois Children’s Services WorkgroupJuly 10, 2014

A broad, flexible array of effective services and supports for defined populations, which:

Is organized into a coordinated network;

Integrates care planning and care management across multiple levels;

Is culturally and linguistically competent;

Builds meaningful partnerships with families and youth at service delivery, management, and policy levels;

Has supportive management and policy infrastructure; and,

Is data-driven.Pires, S. (2010). Building systems of care: A primer, 2nd Edition. Washington, D.C.: Human Service Collaborative for Georgetown University National Technical Assistance Center for Children’s Mental Health.

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System of Care Definition

a set of values and principles that provides an organizing framework for systems reform on behalf of children, youth and families.

Stroul, B. 2005. Georgetown University. Washington, D.C. 3

System of care is, first and foremost,

System of Care Core Values

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Public Heath Approach

SOC Core Values =Health Reform Values

Child Welfare Principles

Systems of care have moved closer to a public health framework:focusing not only on treatment for individual children with serious conditions but also encompassing promotion, prevention, early intervention, and education to improve outcomes and health, developmental and behavioral health status for identified populations of children.

Care that is coordinated across multiple systems and providers and is:•Family-driven and youth-guided •Home and community based•Strengths-based and individualized•Trauma-informed •Culturally and linguistically competent•Connected to natural helping networks•Data-driven, quality and outcomes oriented

Child and Family Services Review (CFSR): •Family-centered practice•Community-based services•Strengthening the capacity of families•Individualizing services

Pires, S. (2009) Building systems of care: A primer 2nd Ed.. & Primer Hands On (2012) Washington, D.C.: Human Service Collaborative.

T. Osher, D. Osher and Blau, FFCMH and CMHS, SAMHSAT. Osher, D. Osher and Blau, FFCMH and CMHS, SAMHSA.

Definition of Family DrivenFamily-driven means families have a primary decision-making role in the care of their own children as well as the policies and procedures governing care for all children in their community, state, tribe, territory and nation. This includes:•choosing culturally and linguistically competent supports, services, and providers•setting goals•designing, implementing, and evaluating programs•monitoring outcomes•partnering in funding decisions

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“Youth Guided means to value youth as experts, respect their voice, and to treat them as equal partners in creating system change at the individual, state, and national level.”

Definition of Youth Guided

www.youthmovenational.org6

National CLAS Standards

• The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (the National CLAS Standards) are intended to:– advance health equity– improve quality– help eliminate health care disparities– (2010) National CLAS Standards Enhancement Initiative launched

to revise the Standards to reflect the past decade’s advancements, expand their scope, and improve their clarity to ensure understanding and implementation.

7Office of Minority Health. US Dept. of Health and Human Services:https://www.thinkculturalhealth.hhs.gov/pdfs/NationalCLASStandardsFactSheet.pdf

Historic/Current Systems Problems

Pires, S. (1996). Human Service Collaborative, Washington, D.C. 8

9

Identified Needs in Illinois*

•Additional care coordination across service systems•Reduce psychiatric hospitalization and residential placements•Reduce segregation of funding that results in fragmentation•Family-driven, youth-guided care•More flexible array of services•Culturally competent services •Maximize funding through blending, braiding, pooling funds•Transparency in utilization and cost data

*Source: DHS: Pathways – Illinois’ Strategic Plan for Children’s Mental Health

Characteristics of Systems of Care as Systems Reform Initiatives

FROM

Fragmented service delivery

Categorical programs/funding

Limited services

Reactive, crisis-oriented

Focus on “deep end,” restrictive

Children/youth out-of-home

Centralized authority

Foster “dependency”

TO

Coordinated service delivery

Blended resources

Comprehensive service array

Focus on prevention/early

intervention

Least restrictive settings

Children/youth within families

Community-based ownership

Build on strengths and resiliency Pires, S. (2010). Building systems of care: A primer, 2nd Edition. Washington, D.C.: Human Service Collaborative for Georgetown UniversityNational Technical Assistance Center for Children’s Mental Health.

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Frontline Practice Shifts

Control by professionals Partnerships with families/youth (I am in charge) (acknowledging a power imbalance)

Only professional services Partnership between natural and professional supports/servicesMultiple case managers One service coordinator Multiple service plans Single, individualized child (meeting needs of agencies) and family plan (meeting needs

of family)Family/youth blaming Family/youth partnershipsDeficits focused Strengths focusedMono Cultural Cultural/linguistic competence

Orrego, M. E. & Lazear, K. J. (1998) EQUIPO: Working as Partners to Strengthen Our Community and Conlan, L. Federation of Families for Children’s Mental Health

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Examples of Family Members & Youth Shift in Roles and Expectations

Lazear, K. & Conlon, L. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C. 12

System Change/Transformation Focus

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

(e.g., data; quality improvement; human resource development; system organization)

(e.g., financing; regulations; rates)

(e.g., assessment; service planning; care management; services/supports provision)

(e.g., partnerships with families and youth; natural helpers; community buy-in) 13

Categorical vs. Non-Categorical System Reforms

Categorical System

Reforms

Non-Categorical

Reforms

Pires, S. (2001). Categorical vs. non-categorical system reforms. Washington, DC: Human Service Collaborative. 14

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Illinois NB v. Hamos Population

All Medicaid-eligible children under the age of 21in the State of Illinois: (1) who have been diagnosedwith a mental health or behavioral disorder; and (2)for whom a licensed practitioner of the healingarts has recommended intensive home-and community-based services to correct or ameliorate their disorders

2 - 5%

15%

80%

More complex

needs

Less complex

needs

IntensiveServices – 60% of $$ Home &

community services and supports;

early intervent’n–35% of $$

Prevention and Universal Health Promotion – 5% of $$

Prevalence/Utilization Triangle

Pires, S. 2006. Human Service Collaborative. Washington, D.C. 16

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Rosie D. Remedy - MassachusettsAmended Medicaid State Plan to cover:•Intensive care coordination using wraparound•Family peer support•Intensive in-home services•Behavioral management therapy and monitoring•Therapeutic mentoring•Mobile crisis intervention…withService definitions tailored to children

Mandated screening by primary care providers for BH issues, use of standardized screens, higher rates, training

Care management entities for children with intensive needs

Common UM criteria across MCOs

Training and TA

Interagency governance through Children’s BH Initiative – Exec. Off. HHS

Have mean Medicaid expenditures (physical and behavioral health care) of $8,520 per year – nearly 5x higher than for Medicaid children in general ($1,729 per year).– TANF children – nearly 3x higher– Foster care – 7x higher– SSI/Disabled – nearly 9x higher

Expenditures are driven more by behavioral health service use than by physical health service use, except for children on SSI/Disabled, for whom mean physical health expenditures are slightly higher.

9.6 % of children using behavioral health care account for an estimated 38% of all spending in Medicaid for children

Pires, SA, Grimes, KE, Allen, KD, Gilmer, T, Mahadevan, RM. 2013. Faces of Medicaid: Examining Children’sBehavioral Health Service Utilization and Expenditures. Center for Health Care Strategies: Hamilton, NJ

Children in Medicaid Using Behavioral Health CareAre an Expensive Population

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What Drives Medicaid Costs (and often poor outcomes) for Children with Behavioral Health Challenges?

•Use of Residential Treatment, Psychiatric Inpatient (& Day Treatment)

•Use of traditional outpatient therapies“Based on current evidence of the effectiveness of interventions in community mental health settings, there is no reason to assumethat the outpatient mental health services provided to foster children are effective in improving outcome” (James, S., Landsverk, J., Slymen, D. and Leslie, L.Predictors of Outpatient Mental Health Service Use—The Role of Foster Care Placement ChangeMent Health Serv Res. 2004 September; 6(3): 127–141)

“Results indicate that children who have experienced long-term foster care do not benefit from the receipt of outpatient mental health services” (Bellamy, J., Gopala, G., Traube, DA national study of the impact of outpatient mental health services for children in long-term foster care. Clin Child Psycholog Psychiatry 2010 Oct;15(4):467-79)

Strategy: Effective home and community-based alternatives and effective OP therapies – e.g. TF-CBT, FFT, PCIT

Pires, S. 2013. Human Service Collaborative

•Inappropriate Use of Psychotropic MedicationsStrategies: Red flag monitoring (too young, too many, too much)and consultation to/education of prescribers as in OR and WY;Psychiatric consultation to primary care docs as in MA (MCPAP);Informed consent supported by access to psychiatric consultationas in IL and VT

•Duplication of Services (e.g., multiple assessments,multiple care coordination)Strategies: fidelity Wraparound approach with dedicatedcare coordinator, low ratios; common screening/assessment tools

What Drives Medicaid Costs (and often poor outcomes) for Children with Behavioral Health Challenges?

Pires, S. 2013. Human Service Collaborative

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Illinois Recommendations*

Focal point of management and accountability at the state levelInteragency structures to set policyAn individualized, wraparound approachFamily-driven, youth-guided servicesStrong youth and family partnership (e.g., involvement in policy, training, funding)Reduce racial, ethnic and geographic disparities and improve cultural and linguistic competence of servicesIncrease use of MedicaidMaximize federal grantsRedeploy funds from higher cost to lower cost servicesOngoing training and t.a. capacityUse data on outcomes and cost across systemsCultivate partnerships with providers, MCOs, others

*Source: DHS: Pathways – Illinois’ Strategic Plan for Children’s Mental Health

Larger Environment

Medicaid re-design: health reform, budget deficits, quality and efficiency

Renewed interest in managed care, including for populations with high use/cost (e.g., chronic conditions, foster care, SSI, SED) Capitated PH/BH – “integrated” designs

Emphasis on integrated care- medical homes, health homes Accountable Care Organization structures Renewed interest in various waivers/options

1115, 1915b, 1915i, Money Follows the Person, health homes

Pires, S. 2013. Washington DC: Human Service Collaborative

Child welfare reform; Juvenile Justice reform

Integrated PH/BH at the Medicaid Purchaser Level

Research has shown that…

When physical and behavioral health dollars are integrated within a capitated managed care environment, there is a risk of behavioral health dollars being absorbed by physical health services

When adult and child behavioral health dollars are integrated, there is a risk of child behavioral health dollars being absorbed by adult services

Especially in the absence of customization within the design for children with serious BH challenges, risk-adjustment strategies, strong contractual performance measures and monitoring mechanisms

See publications and issue briefs published by the Health Care Reform Tracking Project at: http://www.fmhi.usf.edu/cfs/stateandlocal/hctrking/hctrkprod.htm

Accountable Care Organizations• “I believe, with some exceptions, ACOs will not succeed…it will be difficult for anything

but an organization that has been at it a long time to develop the team culture needed to be an ACO”

• “The reason that patient-centered medical homes will not succeed is that health care follows the 80/20 rule - 20% of patients generate 80% of the costs. Those 20% are the chronically ill, and I don’t see how primary care physicians serving those patients add value to their care.”

• “Focused factories of care – that is a term I use for provider organizations that deliver highly specialized care for a certain group of patients, such as those with diabetes…you need specialists for that. They are the opposite of ACOs that do everything for everyone.”--Regina Herzlinger, Harvard Business School, as quoted in Managed Care Magazine

Online (http://www.managedcaremag.com)

REALITY: Care coordination ratios within Medicaid ACOs- for the highest need- run 1:50-75.

Pires, S. 2013. Washington DC: Human Service Collaborative

Analysis of Medical Home Services for Children with Behavioral Health Conditions

“All behavioral health conditions except ADHD associated with difficulties accessing specialty care through medical home”

“The data suggest that the reason why services received by children and youth with behavioral health conditions are not consistent with the medical home model has more to do with difficulty in accessing specialty care than with accessing quality primary care”.

There is a need for more customized, intensive care coordination approaches for children with significant behavioral health challenges.

Pires, S. 2013. Washington DC: Human Service Collaborative

Sheldrick, RC & Perrin, EC. “Medical home services for children with behavioral health conditions”. Journal of Developmental Pediatrics, 2010 Feb-Mar 31 (2) 92-9

Children and Youth with Serious Behavioral Health Conditions Are a Distinct Population from Adults with Serious and Persistent Mental Illness

Children with SED do not have the same high rates of co-morbidphysical health conditions as adults with SPMI

Children, for the most part, have different mental health diagnoses from adults with SPMI (ADHD, Conduct Disorders, Anxiety; not so much Schizophrenia, Psychosis, Bipolar as in adults), and diagnoses change often

Among children with serious behavioral health challenges, two-thirds typically are involved with child welfare and/or juvenile justice systemsand 60% may be in special education – systems governed by legal mandates

Coordination with other children’s systems – child welfare, juvenile justice, schools – and among behavioral health providers, as well as family issues, consumes most of care coordinator’s time, not coordination with primary care

To improve cost and quality of care, focus must be on child and family/caregiver(s) –takes time

Pires, S. March 2013 Customizing Health Homes for Children with Serious Behavioral Health Challenges .Human Service Collaborative

Customized Intensive Care CoordinationApproaches Are Needed

Neither traditional case management nor care coordination approaches for adults are sufficient

•Need lower case ratios•Need higher payment rates•Need approach based on evidence of effectiveness

Customized Care Coordination Approaches for Children with Serious Behavioral Health Challenges(May 7, 2013 CMCS Informational Bulletin)

Care Management EntitiesOrganizations providing intensive care coordination at low ratios (1:10) using high quality Wraparound approach

High Quality Wraparound TeamsProviding intensive care coordination at low ratios

embedded in supportive organization, such as CMHC, FQHC or school-based mental health center

Pires, S. 2013. Washington DC: Human Service Collaborative

Growing number of states – MA, LA, NJ, WI, IL; PRTF Waiver Demo states; CHIPRA Care Management Entity Quality Collaborative states – MD, GA, WY; OK – better outcomes, lower per capita costs, betterfamily and youth experience with system – Triple Aim

The Wraparound Process

• Wraparound is a defined, team-based service planning and coordination process

• The Wraparound process ensures that there is one coordinated plan of care and one care coordinator

• Wraparound is not a service per se, it is a structured approach to service planning and care coordination

• Focuses on the whole youth and family, on developing optimism, self-efficacy and enduring social supports

• Goals are to improve outcomes and youth/family satisfaction and reduce per capita costs of care

National Wraparound Initiative at nwi.org

Role of the Family or Youth Partner

•A peer with lived experience•Assist the family/youth to help them engage and actively participate on the team, and make informed decisions that drive the process. Peer-to-Peer SupportAdvocateCultural Broker(National Wraparound Initiative – Resource Guide to Wraparound )

Penn, M. 2010 Pre-Institutes Training Program, National Technical Assistance Center for Children’s Mental Health, Georgetown University Center for Child and Human Development 30

Wraparound is Increasingly Considered “Evidence-Based”

• State of Oregon Inventory of Evidence-Based Practices (EBPs)

• California Clearinghouse for Effective Child Welfare Practices

• Washington Institute for Public Policy: “Full fidelity wraparound” is a research-based practice

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Examples of Populations Served

• Children in, at risk, for residential treatment, group care• Children in, at risk for detention• Children in, at risk for inpatient psychiatric hospitalization• Children in, at risk for alternative schools• Children staying too long in therapeutic foster care• Children with multiple placement disruptions

States use standardized screening tools (e.g., CANS, CASII) and administrative data (e.g., Medicaid claims) to identify children with intensive BH needs

Creating “Win-Win” Scenarios

System of CareICC/Wrap

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-high cost

Special Education

Alternative to out-of-schoolplacements – high cost

Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.33

Care Management Entity Functions

Pires, S. 2010. Care Management Entities: A primer. Center for Health Care Strategies, Inc.34

“Integration” with Primary Care in a Wraparound Approach

For children with complex behavioral health challenges enrolled in Health Home, Care Management Entity or Wraparound, the Health Team is responsible for:Ensuring child has an identified primary care provider (PCP)Tracking of whether child receives EPSDT screens on scheduleEnsuring child has at least an annual well-child visitCommunicating with PCP opportunity to participate in child and family team and ensuring PCP has child’s plan of care and is informed of changesEnsures PCP has information about child’s psychotropic medication and that PCP monitors for metabolic issues such as obesity and diabetes

Pires, S. 2013. Customizing Health Homes for Children with Serious Behavioral Health Challenges. Hamilton, NJ; Center for Health Care Strategies

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Wraparound Milwaukee (1915 a)

Wraparound Milwaukee. (2010). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and Adolescent Services Branch.

CHILD WELFAREFunds thru Case Rate

(Budget for InstitutionalCare for Children-CHIPS)

JUVENILE JUSTICE(Funds budgeted for

Residential Treatment forYouth w/delinquency)

MEDICAID CAPITATION($1557 per month

per enrollee)

MENTAL HEALTH•Crisis Billing•Block Grant

•HMO Commercial Insurance

Wraparound MilwaukeeCare Management Organization

$47MPer Participant Case Rates fromCW ,JJ and ED range from about$2000 pcpm to $4300 pcpm

Intensive Care Coordination

Child and Family TeamProvider Network210 Providers70 Services

Plan of Care

11.0M 11.5M 16.0M 8.5M

Families United$440,000

SCHOOLSyouth at risk for

alternative placements

Mobile Response & Stabilization co-funded by schools, child welfare, Medicaid & mental health

All inclusive rate (services, supports, placements, care coordination, family support) of $3700 pcpm; care coordination portion is about $780 pcpm

Use CANS

37

UMDNJ Training & TA Institute

Department of Children and FamiliesDivision of Children's System of Care (CSOC)

Dept. of Human ServicesDivision of Medical

Assistance and Health Services (Medicaid)

BH, CW, MA $$ - Single Payor

Provider Network

Contracted Systems Administrator- PerformCare – ASO for child BH carve out

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

Medicaid and DCF-certified providers

Family peer support,education and advocacyYouth movement

Lead non profit agencies managingchildren with serious challenges, multisystem involvement

New Jersey (1115)

*Care Management Entities- CMOs

Family SupportOrganizations

*Care coordination rate of $1034 pcpm

Mobile Response & Stabilization Services

Adapted from State of New Jersey 2010

Use CANS

Massachusetts (1115 Waiver)

MCO MCO MCO MCO PCCM BHO

State Medicaid Agency - Purchaser

*Locally-Based Care Management Agencies (called Community Services Agencies) – Non Profit Specialty

Organizations

•Ensure Child & Family Team Plan of Care•Ensure Intensive Care Coordination•Link to peer supports and natural helpers•Manage utilization , quality and outcomes at service level

Standardized tools for screening and assessment

*Care Coordination Rate: Massachusetts does not use a PMPM rate. However, for comparative purposes , (if assuming a productivity standard of approximately 26 hours a week, and an average caseload of 10), the 15-minute rate for Care Coordination and Family Support &Training may appear to suggest a PMPM of $1,100 - $1,200. 38

Dawn Project Cost Allocation

How Dawn Project is Funded

EX: Redirection and Braided FundsDAWN Project - Indianapolis, IN

2005 CHIOCES, Inc., Indianapolis, IN

RAINBOWS

(Family Organization)

CFT and Care Coordination Structure

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OUTCOMES

New Jersey estimates it has saved over $30m in inpatient costs alone over the past three years and reducedresidential treatment use by 15%.

Wraparound Maine experienced 30% reductions in Medicaid spending with increases in Targeted Case Management and in-home service expenditures and reduction in inpatient and residential expense (net overall 30% spending reduction).

40Pires, S. (2012). “Primer hands On” Washington, D.C.: Human Service Collaborative

OUTCOMES Milwaukee Wraparound

• Reduction in placement disruption rate from 65% to 30%• School attendance for child welfare-involved children improved

from 71% days attended to 86% days attended• 60% reduction in recidivism rates for delinquent youth from one

year prior to enrollment to one year post enrollment • Decrease in average daily RTC population from 375 to 50• Reduction in psychiatric inpatient days from 5,000 days to less

than 200 days per year• Average monthly cost of $4,200 (compared to $7,200 for RTC,

$6,000 for juvenile detention, $18,000 for psychiatric hospitalization)

Milwaukee Wraparound. 2004. Milwaukee, WI. 41

OUTCOMESFamily/Caregiver Experience Milwaukee Wraparound

*Nearly half had previous CPS referral

Very Much So 64%

Not At All 7%

Somewhat 29%

64% reported Wrap Milwaukee empowered them to handle challenging situations in the future (n=188)

72% felt there was an adequate crisis/safety plan in place (n=172)

91% felt staff were sensitive to their cultural, ethnic and religious needs (n=189)

91% felt they and their child were treated with respect (n=191)

Very Much So 72%

Somewhat 13%

Not At All 15%

Very Much So 91%

Somewhat 5%

Not At All 4%

Very Much So

Somewhat

Not At All

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

Very Much So 91%

Somewhat 5%

Not At All 4%

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Regional CareManagement Entities

•Ensure Child & Family Team Plan of Care•Ensure Intensive Care Coordination•Link to peer supports and natural helpers•Manage utilization , quality and outcomes at service level

DCHMCO MCO MCO

DBHDD

ASO

DFCS

DJS

DOE

Potential for Care Management Entities in Georgia:Locus of Management Accountability for Children with

Complex, Multisystem Needs

Use Same Decision Support Toolto determine need for CME

Pires, S. 2008. Washington, D.C.: Human Service Collaborative 43

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. 44

CMS/SAMHSA Informational Bulletin

Benefit DesignBenefit Design

Other Home- and Community-Based Services

• States have also developed service definitions for a variety of additional home and community-based services

• Can be provided through State Plan Amendment, 1915(c) waivers and the 1915(i) program

Additional ServicesAdditional Services

• Therapeutic mentoring

• Supported employment for older youth

• Mental health consultation services

• Telehealth

Example: Broad Service ArrayDawn 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 48

Services/Supports Array Focused on a Total Population

Family Support Services

Youth Development Program/Activities

Coordinated Intake Assessment & Service Planning

Service Coordination Intensive Care

Management Clinical Services School Supports School-Wide Climate

Change InitiativesPires, S. & Isaacs, M. (1996, May) Service delivery and systems reform. [Training module for Annie E. Casey Foundation Urban Mental Health Initiative Training of Trainer Is Conference]. Washington, DC: Human Service Collaborative.

Core Services Prevention Early Intervention Intensive Services

Universal Targeted

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Family & Youth Roles in System of CareRoles Descriptions

Peer Support Services • Information and referral• Parent/Peer education• Family & youth mentors• Supervisor/management

Service Delivery • Peer navigators• Care coordinators• Family & youth support partners• Project directors

Outreach & Public Awareness

• Presentations • Testimony • Community Resource Fairs

Quality Assurance • Evaluation interviewers• Board representation

Training & Technical Assistance

• Curriculum development• Workshops• Co-trainers• Consultants• Certification

50Conlon, L. (2013) Primer Hands On” f Human Service Collaborative: Washington, D.C.

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.51

Provider Network Assessment Tool

1. Incorporates system of care values and practices (e.g., strengths-based, individualized, views families and youth as partners, etc.)

2. Effectively draws on natural helpers as well as formal service providers.3. Includes traditional and non- traditional providers (e.g., community

mental health centers and neighborhood-based organizations).4. Includes culturally and linguistically diverse providers.5. Includes families as providers.6. Includes youth as providers.7. Includes providers of evidence-based and promising practices8. Practices trauma-informed care9. Is a flexible structure so that additions/ deletions to the network can be

made as needed.

1-Does not incorporate SOC values & practices2- Somewhat consistent in incorporating SOC values & practices3-Very consistent in incorporating SOC values & practices

52Pires, S. (2010). Building systems of care: A primer, 2nd Edition. Washington, D.C.: Human Service Collaborative for Georgetown University National Technical Assistance Center for Children’s Mental Health.

Definition of Governance Decision making at a policy level that has legitimacy, authority, and accountability.

Definition of System ManagementDay-to-day operational decision making

Pires, S. (1995). Definition of governance. Washington, DC: Human Service Collaborative. 53

Governance/Management Structure: Louisiana

Children’s System of Care (CSoC) Governing Body

Medicaid, Behavioral Health and Child Welfare

dollars – Medicaid and DMH leads

1915 b and c waivers

Statewide Management

Organization (ASO)

Regional Care Management Organizations

Family Support Organizations

Provider Network

Magellan

54Pires, S. (20012). Primer Hands On – Washington, D.C.: Human Service Collaborative.

State GovernanceEntity in regulation – staffedby DHH/OBHPartners: DHH, DCFS, OJJ, Educ

Private non profitorgs – ICC/Wrap

Maryland

University of MarylandInstitute for Innovation &

Implementation

DHMH DHR DJS

Care ManagementEntity

Contracted private non profit agencymanaging care for children/youth withmultisystem, complex challenges, e.g.Medicaid PRTF, DHR group home,DJS detention diversion

1915 cwaiver

Children’s CabinetGovernor’s Office for Children

Maryland Coalition of Families &Montgomery Co Federation of Families

State Governance Entityin legislationDOE

Care Management Entity: The bundled care coordination rate as of July 1, 2014 will be a full year equivalent of $14,048.62 annual per child (approximately $1170.71 pmpm. )

ASO

How Systems of Care Are Structuring Family and Youth Involvement at Various Levels

Level Structure

Policy Meaningful representation on governing bodies; as membersof teams to write/review requests for proposals and contracts; as members of system design workgroups and advisory boards; raising public awareness; state and local committees

Management As administrators; part of quality improvementprocesses; as evaluators of system performance;as trainers; as advisors in selecting personnel; full time youth coordinator

Services As members of team for own children/youth; servicedelivery providers, such as family support workers,care managers, peer mentors, youth group development,system navigators

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.56

Family-Directed Outreach and Engagement

• Toll-free helpline for support, information and referral• Outreach presentations to diverse provider agencies and

groups and tracking of referrals• Informational booth/family contact during visiting hours

at corrections• Information/family contact at family court for emergency

petitions/child welfare involvement• Information/family contact at the hospital emergency

rooms to support families with children in acute psychiatric needs.

Conlan, L. RI Primer Hands On. 2008 57

Youth-Directed Outreach & Engagement

• Outreach presentations to schools, universities, diverse agencies, and youth drop-in centers

• Informational booth/ youth peer contact at conferences/ health fairs

• Youth peer warm- line for support & resources

• Youth-led Recovery Panels• Resource/ youth peer contact at

DSS/court settings

59

Family run organizations or chapters connected toa statewide family-run organization in each region

Use family specialists (at DMH, at SOC sites, etc) to help build capacity

Finance with dollars from all children’s agencies(e.g. Medic admin, mental health block grant, childwelfare, etc), as well as grants

Suggested Strategy to Expand Family Voice

Parent Support Network of RI

60Conlon, L. (2013) Primer Hands On.

Organized Pathway to Care

Multiple Entry Points

+ more accessible- loss of entry control- loss of quality control+-

One Access Point

+ less confusing+ more entry control- inaccessible--

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

Use standardized screening and assessment tools (e.g., CASII, CANS, trauma-informed)One pathway to Care Management Entities for multi-system involved children thru designated: population criteria (cross-agency), screening tools; screeners; CMEsDevelop data sharing agreements; integrated electronic record for children with complex needsRole for family/youth peer partners in intake, system navigation, support, information and referral

61

Statewide Quality Improvement Initiative - Michigan

Uses data on child/family outcomes (CAFAS) to:

Focus on quality statewide and by siteIdentify effective local programs and practicesIdentify types of youth served and practices associated with good outcomes (and practices associated with bad outcomes)Inform use of evidence-based practices (e.g., CBT for depression)Support providers with training informed by dataInform performance-based contracting

QI Initiative designed and implemented as a partnership among State, University and Family Organization

K. Hodges. & J. Wotring. 2005. State of Michigan.

62

State Structures in Place to Support Capacity Building

Maryland Institute for Innovation and Implementation

California Institute of Mental Health

Ohio Center for Innovative Practices

Developing “Centers of Excellence”(GA, RI)

Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative. 63

Financing Strategies and Structures to Support Improved Outcomes for Children, Youth and Families 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.

REDEPLOYMENTUsing the money we already haveThe cost of doing nothingShifting funds from high cost/poor outcomeservices to effective practicesMoving 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 collections including child supportTrust 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

64

Redirection

Where are you spending resources on high 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 psychological

evaluations?65Pires, S. 2006. Human Service Collaborative. Washington, D.C.

EX: Redirected and Pooled FundsWraparound Milwaukee

Wraparound Milwaukee. (2010). What are the pooled funds? Milwaukee, WI: Milwaukee County Mental Health Division, Child and Adolescent Services Branch.

CHILD WELFAREFunds thru Case Rate

(Budget for InstitutionalCare for Children - CHIPS)

JUVENILE JUSTICE(Funds budgeted for

Residential Treatment forYouth in JJ system)

MEDICAID CAPITATION($1843 per month

per enrollee)

MENTAL HEALTH•Crisis Billing•Block Grant

•HMO Commercial Insurance

Wraparound MilwaukeeManagement Service Organization (MSO)

$47mPer Participant Case Rate

Care Coordination

Child and Family TeamProvider Network210 Providers70 Services

Plan of Care

$11M $11.5M $16M $8.5M

Families United$440,000

SCHOOLSnew partner

66

EX: Redirection and Braided FundsCuyahoga County (Cleveland)

FCFC $$Fast/ABC $$Residential Treatment Center $$$$Therapeutic Foster Care $$$“Unruly”/shelter care $$Tapestry $$SCY $$

County Administrative

Services Organization

Neighborhood Collaboratives &Lead Provider Agency

Care CoordinationPartnerships

Community Providers and Natural Helping Networks

Reinvestment of savings

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

}

}

StateEarly Intervention and Family Preservation $$

System of Care Grants

System of Care Oversight Committee

Child and Family Team Plan of Care

67

Examples of Refinancing

Milwaukee County, WI •Schools and child welfare contributed $450,000 each to expand mobile response and stabilization services (prevent placement disruptions in child welfare, prevent school expulsions) •MRSS is a Medicaid-billable service; contributions from schools and child welfare generate $180,00 to the school contribution and $200,000 to child welfare’s in Federal Medicaid match dollars, creating:

A $650,000 program expansion for child welfareA $630,000 program expansion for the schools

68Pires, S. 2012, Human Service Collaborative. Washington, D.C.

New Jersey Refinancing

69NJ System of Care

70

Examples: Raising New Revenue

Summary of Financing Characteristicsof Systems of Care for Children and Families

Maximize Medicaid (e.g., flexible Rehab Option)Blend, braid or intentionally coordinate funding streams across systemsRe-direct spending from high cost and/or poor outcome services to

effective practicesManage dollars through managed care arrangements that are tied to

values and goalsRisk adjust payment for complex populations of children (e.g., risk-

adjusted capitation rates to MCOs; case rates to providers)Finance locus of accountability – e.g., care management entities for

most complex, cross-systemFinance family and youth partnerships at policy, management and

service levelsFinance training, capacity building, quality and outcomes monitoring

Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.71

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

72Pires, S. 2006. Human Service Collaborative. Washington, D.C.

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.” (Source: 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)

“…greater use of residential treatment centers by black persons and Hispanic persons that is attributable in part to (public sector) managed care”(Source: 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)

73Pires, S. 2008. Human Service Collaborative. Washington, D.C.

Federal Medicaid Guidance7/11/13 State Medicaid Director’s Tri-Agency Letter onTrauma-Informed Treatment http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-07-11.pdf

5/7/13 Informational Bulletin on Coverage of Behavioral Health Services for Children,Youth and Young Adults with Significant Mental Health Conditionshttp://www.medicaid.gov/federal-policy-guidance/downloads/CIB-05-07-2013.pdf

3/27/13 Informational Bulletin on Prevention and Early Identification of MentalHealth and Substance use Conditionshttp://www.medicaid.gov/federal-policy-guidance/downloads/CIB-03-27-2013.pdf

8/24/12 Informational Bulletin on Resources Strengthening the Management of Psychotropic Medications for Vulnerable Populationshttp://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-08-24-12.pdf

11/21/11 State Medicaid Directors Tri-Agency Letter on Appropriate Use ofPsychotropic Medications Among Children in Foster Carehttp://www.medicaid.gov/federal-policy-guidance/downloads/SMD-11-23-11.pdf

Resources

Building Systems of Care: A primer, 2nd Editiongucchd.georgetown.edu/64273.html

Faces of Medicaid: Examining Children’s Behavioral Health Service Utilization and Expenditureshttp://www.chcs.org/publications3960/publications_show.htm?doc_id=1261588#.U1gmMvldUud

Making Medicaid Work for Children in Child Welfare: Examples from the Fieldhttp://www.chcs.org/usr_doc/Making_Medicaid_Work.pdf

Customizing Health Homes for Children with Serious Behavioral Health Challengeshttp://www.chcs.org/usr_doc/Customizing_Health_Homes_for_Children_with_Serious_BH_Challenges_-_SPires.pdf

Psychotropic Medications Quality Improvement Collaborative:Improving the Use of Psychotropic Medications Among Children in Foster Carehttp://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1261326

CHIPRA Care Management Entity Quality Collaborativehttp://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1250388

Return on Investment in Systems of Care for Children with Behavioral Health Challengeshttp://gucchdtacenter.georgetown.edu/publications/RISOCs.pdf

For further information, contact:

Sheila A. PiresHuman Service Collaborative

sapires@aol.com