Maximizing Opportunities to Increase Child and Family Well Being Through Innovative Funding Approaches

1. Because Minds Matter: Collaborating to Strengthen Psychotropic Medication Management for Children and Youth in Foster Care Maximizing Opportunities to Increase Child and Family Well Being Through Innovative Funding Approaches Sheila A. Pires Human Service Collaborative Washington, DC August 27-28, 2012 Washington, DC

2. 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.

3. 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.

4. Broad, Flexible Service ArrayExample:Dawn Project Services & Supports 2005 CHIOCES, Inc., Indianapolis, IN

5. 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 5

6. Examples of Sources of Funding for Children/ Youth • 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 • Mental Health • MH General Revenue • MH Medicaid Match • MH Block Grant • 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 • Child Welfare • CW General Revenue • CW Medicaid Match • IV-E (Foster Care and Adoption Assistance) • IV-B (Child Welfare Services) • Family Preservation/Family Support • Substance Abuse • SA General Revenue • SA Medicaid Match • SA Block Grant • Juvenile Justice • JJ General Revenue • JJ Medicaid Match • JJ Federal Grants Pires, S. (1995). Examples of sources of behavioral health funding for children & families in the public sector. Washington, DC: Human Service Collaborative.

7. Financing Strategies and Structures FIRST PRINCIPLE: System Design Drives Financing 7 Adapted from Friedman, M. (1995). Financing strategies to support improved outcomes for children. Washington, DC: Center for the Study of Social Policy.

8. 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?

9. 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.

10. 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

11. 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 treatment centers by black persons and Hispanic persons that is attributable in part to (public sector) managed care” (2) 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 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

12. Strategic Financing Analysis • Identify state and local agencies that spend on youth/families at risk • How much? What kind of $? • Identify resources that are untapped or under-utilized (e.g., Medicaid) • Identify utilization patterns and expenditures • Consider high cost/poor outcome Pires, S. 2006. Human Service Collaborative. Washington, D.C.

13. Strategic Financing Analysis 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 strategies Federal revenue maximization; re-direction from restrictive levels of care; waiver; performance incentives; legislative proposal; taxpayer referendum

14. Aligning Incentives Across Agencies Child Welfare Medicaid Alternative to out-of-home care high costs/poor outcomes Alternative to IP/ER/PRTF; multiple psychotropic meds System of Care Alternative to detention-high cost/poor outcomes Alternative to out-of-school placements, high special ed costs Juvenile Justice Education 14 Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

15. New Jersey BH, CW, MA $$ - Single Payer Department of Children and Families Division of Child Behavioral Health Services Dept. of Human Services Medicaid Division UMDNJ Training & TA Institute Contracted Systems Administrator- PerformCare • 1-800 number • Screening • Utilization management • Outcomes tracking Provider Network Family Support Organizations Care Management Organizations - CMOs Any licensed DCF provider Family peer support, education and advocacy Youth movement Lead non profit agencies managing children with serious challenges, multi-system involvement 70

16. Louisiana Children’s System of Care (CSoC) Governing Body 1915 b and c waivers Medicaid, Behavioral Health and Child Welfare dollars Statewide Management Organization (ASO) Magellan Regional Care Management Organizations Provider Network Family Support Organizations

17. Care Management Entity Functions At 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

18. Affordable Care Act Opportunities and Challenges • Medicaid Re-Design • Renewed interest in various waivers/options • 1115, 1915b, 1915i, Money Follows the • Person, health homes • Renewed interest in managed care, including • for populations with high use/cost (e.g., chronic • conditions, foster care, SSI)

19. I. Customizing Medicaid Managed Care for Children/Youth in Child Welfare and At Risk Requirements for: • Incorporation of State and federal requirements for child welfare • population, 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 children • with serious behavioral health challenges • Special liaison for child welfare-involved children, • children enrolled in Care Management Entities, youth transitioning • Hire/contract with family and youth organizations to serve as • family and youthadvocates and peer supports • Incentives to require out-of-office care • Specific performance measures related to children in child welfare • Reinvestment back into child home and community services Pires, S. 2012.Washington DC: Human Service Collaborative

20. II. Customizing Medicaid Managed Care for Children/Youth in Child Welfare and At Risk Requirements for: • EPSDT inclusion of behavioral health screens and linkage • to BH services when indicated • Broad BH benefit, inclusive of in-home, respite, family and • youth peer support, mobile response and stabilization, behavioral • management consultation, therapeutic foster care, telebehavioral health • Provider network requirements to include: providers trained • in child welfare population issues, EBPs, trauma-informed care; • racially/ethnically diverse providers; inclusion of families/youth as • providers/advocates • Enhanced rates for providers trained in EBPs and trauma- • informed care • Timely provider payments Pires, S. 2012. Washington DC: Human Service Collaborative

21. III. Customizing Medicaid Managed Care for Children/Youth in Child Welfare and At Risk Requirements for: • No “fail first” policies regarding access to service type or • psychotropic med type • Specific “pass-through” case rate for Care Management Entity • or wraparound team approach for children with most complex • challenges • Use of standardized tools for screening, and determination of • service intensity needed • Prior authorization parameters that enable “ready access” to • services (e.g., first 12 visits do not require prior auth) • Prior authorization parameters that allow wraparound plan of • care to drive medical necessity (with outlier management) Pires, S. 2012. Washington DC: Human Service Collaborative

22. IV. Customizing Medicaid Managed Care for Children/Youth in Child Welfare and At Risk Requirements for: • Quality review process that involves families and youth • with lived experience on quality review teams and requires • input from child welfare system • Data tracking requirements to include: service use • and expenditures of children in foster care, including psychotropic • meds – stratifiableby age, gender, race/ethnicity, aid category, • region, diagnosis, service type, medication type • Engagement in quality improvement initiatives involving • children’s behavioral health and children in child welfare • Focus groups and satisfaction surveys of youth and families • involved in child welfare and of child welfare workers Pires, S. 2012. Washington DC: Human Service Collaborative

23. Summary of Financing Characteristics of Systems of Carefor Children/Youth and Families in Child Welfare and At Risk • Maximize Medicaid (e.g., flexible Rehab Option) • Blend, braid or intentionally coordinate funding streams • across systems • Re-direct spending from high cost and/or poor outcome • services to effective practices • Manage dollars through managed care arrangements that • are tied to values and goals • Risk 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-system • Finance family and youth partnerships at policy, management • and service levels • Finance training, capacity building, quality and outcomes monitoring Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

24. For further information, contact: Sheila A. Pires Human Service Collaborative sapires@aol.com