Managing Residential Care to Improve

Permanency Outcomes

Presented by: Dr. Peter Mendelson, Chief, Bureau of Behavioral Health and Medicine, DCF

Lori Szczygiel, MA, CEO ValueOptions Connecticut

Goals

The goal of residential care is to return youth to community settings ~ ideally to families

Youth in Residential Care deserve intensive behavioral health treatment which explicitly focuses

on returning them to their families with help and with hope

DCF and ValueOptions share a goal of increasing the availability of community services while decreasing the need for out of home service

We are committed to stopping the “Residential Shuffle” and to fostering permanency and post-placement stability

Public and Private Partnership to Effectuate Change

DCF and Medicaid in CT contract with an Administrative Service Organization (ASO), ValueOptions (VO), to provide a variety of utilization and quality management functions for the Connecticut Behavioral Health Partnership

Residential management, tracking, reporting and outcome monitoring represent significant components

Functions and staff (DCF and VO) are integrated within a Residential Care Team

Partnership, cont’d

10 ValueOptions staff and 10 DCF staff manage: 633 youth in residential placement Admission process (determine level of care via state

constructed guidelines and medical necessity) Frequent concurrent reviews and monitoring Referral and Tracking Reporting Analysis Quality monitoring and management via reporting and

on-site reviews

Understanding the Needs and Opportunities

Two years of data have been tracked and trended: Number of youth approved for out of home care Average length of stay Discharge delay Risk management data (AWOLs, Arrests, Restraints, etc.)

In 2008 DCF and VO established a workgroup to track and analyze 13 RTC outcome measures previously agreed upon by the Department and residential providers

Understanding the Needs and Opportunities, cont’d

Our workgroup began the development of a Provider Analysis and Reporting (PARs) program to analyze residential services and to refine and incorporate outcomes in order to achieve enhanced rates of permanency

PARs program is a quality improvement process with various action steps

Providers are evaluated against generally accepted industry utilization and quality measures

We provide regular feedback and support to providers to support performance improvement

Understanding the Needs and Opportunities, cont’d

Second phase of PARs entails the attachment of financial incentives to the accomplishment of stated performance goals ~ a Performance Incentive Program (P4P)

Quarterly PARs meetings since 2009 (aggregate data shared in statewide forum)

Bi-annual, provider specific PARs program rolled out in CY 2009

Performance Incentive program under construction of CY 2010

Looking at Outcomes – Opportunities for Improving

Permanency Research shows that a child’s experience in placement directly impacts post placement stability and permanency

In placement metrics measured: Length of time to achieve readiness for discharge Average number of days children remain in placement beyond clinical

necessity Notable events while in placement Attendance in school Average number of hours the child is in treatment while in placement Average number of hours of family treatment Average number of hours spent on specific activities which will support

post-placement permanency (family readiness, individualized supports, etc.)

Looking at Outcomes – Opportunities for Improving

Permanency, cont’d Post Placement metrics measured: Percentage of children discharged to a lower level of care Percentage of children discharged to a lower level of care

maintaining stability for 12 months 0 – 180 day post placement stability

% of children hospitalized % of children arrested % of children readmitted to residential

All of the above measures are designed to document outcomes post placement. Our intervention fails if stability and permanency are disrupted after a course of residential treatment

Overall Trends

Some improvement has been seen but there is more work to be done

1/3 of the children served did not maintain permanency and post-placement stability

Baseline Performance – Average Length of Time to Achieve Readiness

for Discharge

198

22495

0

50

100

150

200

250

300

350

400

# o

f D

ay

s

Statewide 330 300 287

CY '08 CY '09 YTD '10

∙ Average length of time has decreased by 13% between CY ’08 and YTD ‘10

Baseline Performance-Percentage of Children Discharged from RTC to a

Lower Level of Care 198

22395

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

% o

f C

hil

dre

n D

isch

arg

ed

LLOC Discharges 48% 53% 55%

CY '08 CY '09 YTD '10

· Percentage of children discharged to a lower level of care has increased by 7% from CY ’08 to ‘10 YTD

Baseline Performance-Percentage of Children Hospitalized 0-180 days Post

RTC Discharge

46

61

11

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

% o

f C

hil

dre

n H

osp

ital

ized

% of Children Hospitalized 10% 14% 13%

CY '08 CY '09 Q1 '10

Baseline Performance-Percentage of Children Arrested 0-180 days Post

RTC Discharge

14

17

13

10 54

0%

5%

10%

15%

20%

25%

30%

% o

f C

hil

dre

n A

rres

ted

% of Children Arrested 23.3% 26.6% 18.3% 22.2% 22.5%

Q1 '09 Q2 '09 Q3 '09 Q4 '09 CY '09

Baseline Performance-Percentage of Children Readmitted 0-180 days Post

RTC Discharge101

91

12

0%

5%

10%

15%

20%

25%

30%

% o

f C

hil

dre

n R

ead

mit

ted

% of Children Readmitted 23% 21% 15%

CY '08 CY '09 Q1 '10

· Percentage of children readmitted decreased by 8% from CY ’08 to ’10 YTD

Number of RTC Admissions

▪ RTC admissions have decreased by 12% between CY ’08 and CY ’09.

0

100

200

300

400

500

600

700

800

900

# o

f A

dm

its

Children 635 721 632

CY '07 CY '08 CY '09

Number of IICAPS Admissions

▪ IICAPS admissions have increased by 92% between CY ’07 and CY ‘09

0

200

400

600

800

1000

1200

1400

# o

f A

dm

its

Children 644 965 1236

CY '07 CY '08 CY '09

What Have We Learned?

To support stability and permanency, investment must occur within the community delivery system

For many youth, investment in community services has led to a decrease in residential admissions and to the preservation of families

Youth that do get admitted to residential programs are more challenging in terms of clinical presentation

What Have We Learned, cont’d?

Focus is critical: Family Readiness is more important than “Fixing” the child

Provider Analysis and Reporting and Performance Incentive Programs identify goals to support permanency and financially reward providers for positive outcomes

Providers at rest tend to stay at rest