Presented By: Angelo McCain, PhD Commissioner Massachusetts Dept of Social Services

1. Improving Child & Family Well-Being Through Creative Financing StrategiesSession Xat: Because Minds Matter: Collaborating to Strengthen Medications for Children & Youth in Foster CareWashington DC – August 27 – 28, 2012 Presented By: Angelo McCain, PhD Commissioner Massachusetts Dept of Social Services Janice DeFrances, Ed.D Director Rhode Island Dept of Children, Youth & Families Sheila Pires, MPA Partner, Human Service Collaborative, DC Bruce Kamradt, MSW Administrator of Childrens Mental Health Services/Wraparound Milwaukee, WI

2. What is Wraparound Milwaukee It is a unique “system of care” for children and adolescents with serious emotional, behavioral and mental health needs and their families designed to achieve better child and family outcomes at less cost Serves Milwaukee County – 1 million population The program serves over 1,400 (950 avg daily enrollment) families annually with a budget of $47 million per year 70% of youth served are under the jurisdiction of Child Welfare or Juvenile Justice

3. What is Wraparound Milwaukee – cont’d Youth served are those with complex needs at immediate risk of institutional care in residential treatment facilities, psychiatric inpatient facilities or juvenile correctional facilities Our approach is based on a set of core values and principles that put child and family well being at the center of the service systems

4. Elements of Wraparound Values & Principles

5. How is Wraparound Milwaukee Structural & Organized Publically operated Care Management Entity (CME) – operated by Milwaukee County Behavioral Health Division to care for SED youth regardless of the child serving system they come from and are involved with Integrated delivery of behavioral health and supportive services across child serving systems for SED youth Pooled funding across systems Single payor of all care, including mental health, substance abuse, supportive services and out-of-home care minus physical care One care plan – one care coordinator Extensive service array and provider network Family directed – youth guided

6. How is Wraparound Milwaukee Structural & Organized – cont’d It is type of a behavioral health carve-out under a 1915(a) contract between Milwaukee County Human Services and State Dept. of Health but is more comprehensive because it covers the delivery of services for children and families beyond what Medicaid would normally cover While it does not directly cover physical health care costs it coordinates with the primary care physician particularly around special health conditions and use of psychotropic medication

7. Why was Wraparound Milwaukee Created Overutilization of institutional placements for children in mid – 1990’s particularly residential treatment, psychiatric hospitalization and juvenile correctional placements Poor outcomes of youth utilizing these out-of-home placements Overuse of high-cost institutional care was causing financial problems for Milwaukee County and Medicaid System needed better oversight, accountability and more community-based alternatives

8. What are Components of Wraparound Milwaukee Care Management Model Using a Care Management Entity (CME) model, it oversees care of all children with serious emotional and mental health needs across child serving systems Does fiscal management of system Contracts with other child serving agencies ex. Medicaid, Child Welfare, Juvenile Justice, etc. Provides assessment/screening of youth eligible for enrollment Provides or contracts for care coordination services (1:10 ratio)

9. What are Components of Wraparound Milwaukee Model – cont’d Operates 24/7 mobile crisis intervention services Creates and manages a Provider Network of 200 agencies with 60 different services Provides clinical and medical supervision of behavioral health areas Operates a single IT system and electronic health record (minus physical health) Conducts Quality Assurance/Quality Improvement and Program Evaluation

10. Wraparound Milwaukee’s Funding Model Creates a funding pool through various funding arrangements Medicaid – actuarial determined capitated rate plus fee-for-service for crisis services Child Welfare – case rate agreement covering non-medicaid provided services particularly out-of-home care costs Delinquency Services – fixed annual funding based on 1995 expenditures ($8 million) plus a monthly case rate for diversions from juvenile corrections Principle approach is to re-direct money from institutional placement expenditures to community-based care Wraparound Milwaukee is the single payor for all services for enrolled youth, is at risk for service costs and therefore has incentive to insure most appropriate , cost effective care

11. Creating “win-win” Scenarios Child Welfare Medicaid Alternative to out-of-home care high costs/poor outcomes Alternative to IP/ER-high cost System of Care Alternative to residential & Correctional placements Alternative to day treatment costs Juvenile Justice Special Education

12. How We Pool Funds CHILD WELFARE JUVENILE JUSTICE MEDICAID CAPITATION MENTAL HEALTH Funds thru Case Rate (Funds Budgeted for (2052per Month per Enrollee) •CRISIS BILLING (Budget for Institutional Residential Treatment and HTI GRANT • Care for Chips Children) Juvenile Corrections Placements) HMO COMMERCIAL INSUR • 10.0M 10.0M 20.0M 7.0 M WRAPAROUND MILWAUKEE CARE MANAGEMENT ORGANIZATION (CMO) 47.0M CARE COORDINATION OR TRANISITIONAL SPECIALIST PROVIDER NETWORK 210 Providers 60 Services FAMILIES UNITED $400,000 CHILD & FAMILY TEAM OR TRANSITION TEAM PLAN OF CARE OR FUTURES PLAN

13. Advantages of Blended or Pooled Funding Model Flexibility Adequacy of funding De-Categorization of funds Responsive to changing needs Lends itself to positive manage care approach – don’t need to “ration care” De-Politicalizes allocation and awarding of funds

14. Outcomes for the System & Youth Served in Wraparound Milwaukee Outcomes currently being measured include programmatic, fiscal, clinical, public safety, child permanency and consumer satisfaction Programmatically – the average daily residential treatment population has dropped from 375 youth to 80 youth, inpatient psychiatric days from 5000 to under 500 days per year Fiscally – the averages cost for a child/family in Wraparound is under $4000 per month versus over $10,000 per month for a residential treatment placement, over $9000 per month for a correctional placement or well over $10,000 for a 7-day hospital stay Clinically – children function better at home, school and in the community based on administration of nationally normed measures such as the CBCL (Achenbach) used at the time of enrollment and discharge

15. Outcomes for the System & Youth Served in Wraparound Milwaukee – cont’d Public Safety – recidivism rates for delinquents are low (15.2%) for youth in the program for at least one year and even lower (6.7%) for high risk offenders including juvenile sex offenders (this is considerably under national standards) Child Permanence – 80% of youth achieve permanency, i.e., return to parents, relatives, adoptive resources or subsidized guardianship upon leaving Wraparound Family Satisfaction – families surveyed upon completing Wraparound (average 18 months) gave the program a rating of 4.4 out of 5 points in terms of their perception of the progress their child made while in the program

16. Cost of Doing NothingResidential Treatment Placements & Costs Without Wraparound Milwaukee Child Welfare/Juvenile Justice Expenditures for RTC without Wraparound Milwaukee RTC Placements 63.4 57.5 Potential Increase in RTC Placements w/o Wraparound Milwaukee (5% growth with NO Change in LOS) RTC Rate Increase of 5%/year With 5% Increase of No. of Placements 52.2 47.4 43.0 38.9 35.6 32.3 29.2 26.6 24.1 22.0 * 19.9 18.4 * Average Daily Census of Youth In RTC’s Average RTC Rate and Total Projected Annual Expenditures *Actual Number of Placements and Costs for That Year