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

1. Collaboration to Strengthen Management of Psychotropic Medications for Children in Foster Care Maximizing Opportunities to Increase Child and Family Well Being Through Innovative Funding Approaches A Look at Massachusetts Angelo McClain, Ph.D., LICSW Commissioner, Massachusetts Department of Children and Families

2. Children’s Behavioral Health Initiative • How it came about: • Federal Medicaid program mandates Early Periodic Screening Diagnosis and Treatment (EPSDT) for children under 21. • Class action suit filed in Massachusetts in 2001, court found in 2006 that Massachusetts in violation of EPSDT provisions of the Federal Medicaid Act • Orders State to develop in-home services, including comprehensive assessments, case management, behavior supports, and mobile crisis services • Who is Eligible: • Children with SED, In addition to any other disabling condition, such as autism spectrum disorders, developmental disability o substance abuse 2

3. Children’s Behavioral Health Initiative Service Array • Intensive Care Coordination (ICC; Wraparound) • Family Support & Training (FS&T; Family Partners) • In-Home Therapy (IHT) • In-Home Behavioral Services (IHBS) • Therapeutic Mentoring (TM) • Mobile Crisis Intervention (MCI) • Crisis Stabilization (CS) ( Approval denied by CMS) 3

4. Children’s Behavioral Health Initiative Systems Overview HUB SERVICES • Additional • Services • (accessed • through • core clinical • services) • Behavior • Management • Therapy & • Monitoring • Family Partners • Therapeutic • Mentoring • Intensive Care Coordination • (Wraparound) • Clinical Assessment inc. CANS • SED determination for eligibility • Medical Necessity determination • Care coordination • Families • decide on • most appropriate • initial service • independently • or in consultation with • helping professions such as: • primary care, • mental health clinicians • schools • case workers • community orgs • faith leaders • others • In-Home Therapy • Clinical Assessment inc. CANS • Medical necessity determination • Care coordination available • Outpatient Therapy • Clinical Assessment inc. CANS • Medical necessity determination • Care coordination available Emergency Services Mobile Crisis Intervention 4 7/15/2014 Crisis Stabilization

5. Leveraging Funding • The Rosie D Judgment: • Included language that required MassHealth to pay for the new services, to the degree that Federal approvals are obtained and Federal Financial Participation is available • MassHealth sought maximum clarity from CMS by seeking to add the remedy services to its Medicaid State Plan, through “State Plan Amendments” (SPAs) 5

6. Financing Through State Plan AmendmentOpportunities and Risks Pros: • Financial Partner to share cost…….not only state contributions • Provide clear authority, not dependent upon periodic waiver renewals Cons: • Can be costly to implement • Services must be available statewide • Must meet medical necessity criteria 6

7. Seeking Approval of SPAs… …is an art and a science • You need your Medicaid staff who regularly work with CMS • There are often policy and financial contexts, strategic considerations, for every request and every decision, no matter how minor • Value of Subject Matter Experts (SMEs), e.g. a consultant with recent experience working on CMS submissions • CMS staff in different regions can make different decisions – stay connected to your networks 7

8. Caring TogetherStrengthening Children and Families Through Community-Connected Residential Treatment • Joint partnership between the Massachusetts Department of Mental Health & Department of Children and Families • A bold new approach to delivering residential services for children and youth • Integrated placement & community treatment • Services “flex” to meet child’s changing needs • Parent Partners • IV – E Waiver • Application Pending • Use $$ currently reimbursing placement to purchase “Residential Level of Service” in the community. 8

9. TRADITIONAL SERVICE SYSTEM CARING TOGETHER SERVICE SYSTEM Child Family DMH Door DCF Door Multiple doors ONE DOOR $$ $$ JOINT ENTRANCE REQUIREMENTS DMH Entrance Requirements DCF Entrance Requirements Joint System Management DMH Area Offices (6) DCF Area Offices (29) Same Clinical Team Residential Level of Service Transition Services Case Management Provider A Provider B Provider C Provider D Behavioral Health Improved access to seamless residential treatment and community based services for children and families

10. Benefits to Children and Families • Integrates the way service are delivered to better respond to families’ needs • Maximizes flexibility of services and resources • Shifts paradigm to recognize the importance of delivering clinically intensive services primarily within a child’s “home community” • Keeps more families together; and reunites others more quickly 10

11. Paying for Performance • Year 1 – Unbundled Payments • Implement IV – E Waiver Program (pending approval) • Gather Data While Providers Learn New Business • Build Consensus on Performance Measures • Year 2 – Establish Case Rate • Blended Placement & Non-Placement • Ex. 30 Placement; 20 Community = $240 / day • Incentive to Increase Community Tenure • Year 3 – Establish Well-Being Incentives • Strengthening Families / Positive Youth Development • Ex. Reduce Repeat Maltreatment; Educational / Vocational Success; Reduce Reliance on Psychotropic Medication 11

12. Multiple Payers – One Integrated Service CHILD WELFARE State Appropriation (FFP Goes to General Fund) MENTAL HEALTH State Appropriation MEDICAID CBHI $200M $40M CARING TOGETHER Integrated Residential Treatment For Children and Families EDUCATION Special Education Services COMMUNITY SERVICES FRC; Informal Supports

13. Family Partner – Braiding the Funds to Change Payer, NotPartner