Governance and System Management

1. Governance and System Management Sheila A. Pires Human Service Collaborative sapires@aol.com Lisa Conlan Parent Support Network of Rhode Island lisaconlan2@aol.com Michelle Zabel University of Maryland mzabel@psych.umaryland.edu Bruce Strahl Technical Assistance Partnership bstrahl@ffcmh.org

2. Definition of Governance Decision making at a policy level that has legitimacy, authority, and accountability. Definition of System Management Day-to-day operational decision making 2 Pires, S. (1995). Definition of governance. Washington, DC: Human Service Collaborative.

3. Key Issues for Governing Bodies • Has authority to govern • Is clear about what it is governing • Is representative • Has the capacity to govern • Has the credibility to govern • Assumes shared liability across systems for the population(s) of focus 3 Pires, S. (2000). Key issues for governing bodies. Washington, DC: Human Service Collaborative.

4. Examples of Types of Governance Structures • State and/or local interagency body • Non profit board of directors • Quasi governmental entity • Tribal governance • Hybrids Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative. 4

5. System Management: Day-to-Day Operational Decision Making Key Issues Is the reporting relationship clear? Are expectations clear regarding what is to be managed and what outcomes are expected? Does the system management structure have the capacity to manage? Does the system management structure have the credibility to manage? 5 Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

6. Examples of Types of System Management Structures • State and/or local interagency body • Quasi-governmental entity • Non profit lead agency • Public sector lead agency • For profit commercial managed care entity • Shared management structure/hybrid • Tribal authority 6 Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

7. New Jersey - Contracted Management Structure Other School Referral Family &Self CHILD Child Welfare Juvenile Justice/ Court Community Agencies Screening with Uniform Protocols • Contracted • Systems • Administrator CSA • Registration • Screening for self-referrals • Tracking • Assessment of level of care needed • Care coordination • Authorization of services • Care Management • Organization • Complex multi-system • involved children • Individualized plan developed • Full plan of care • authorized • Community • Agencies • Uncomplicated care • Service authorized • Service delivered Adapted from NJ System of Care Family Support Organization Family to Family Support Youth Support Organizations 7

8. Wraparound Milwaukee - Lead Public Agency Management Structure • Mental Health • Crisis Billing • Block Grant • HMO Commercial • Insurance Child Welfare Funds thru Case Rate (Budget for Institutional Care for CHIPS Children) Juvenile Justice (Funds Budgeted for Residential Treatment for Delinquent Youth) Medicaid Capitation (1557 per Month per Enrollee 9.5M 8.5M 10M 2.0M Management Entity: Wraparound Milwaukee Management Service Organization (MSO) $30M Family Organization $300,000 Per Participant Case Rate Provider Network 240 Providers 85 Services Care Coordination Child and Family Teams Plans of Care Mgt. Entity: Co. BH Div. 8 Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee County Mental Health Division, Child and Adolescent Services Branch

9. Cuyahoga County OH - In-House Management Structure System of Care Oversight Committee Deputy County Administrator for Human Services Systemof Care Office* { Lead Family Coordinator { Lead Youth Coordinator Subsets of Children & Families – Focus of Care Coordination Partnerships Children in or at risk for residential placement Children with serious behavioral health challenges Youth with status offenses 0-3 population Early Intervention engagement challenges *Functions as an Administrative Services Organization 9 Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

10. Care Management Entities: Locus of management accountability for children with complex, multi-system involvement Regional Care Management Entities DCH MCO MCO MCO MHDDAD ASO TPA • Ensure child & family team plan of care** • Ensure intensive care coordination • Manage utilization at service • level • **Plans of Care (w/priority on • community-based/natural • supports) determine medical • necessity, except inpatient, residential/group, which require prior authorization DFCS DJS DOE Use Same Decision Support Tool – CANS – to determine need for CME 10 10 Pires, S. 2008. Washington, D.C.: Human Service Collaborative

11. At the Youth & Family Level: Child Family Team (CFT) Facilitation using Wraparound Model Care Coordination with assessment tools Care Monitoring and Review Peer Support Partners At the Systems Level: Information Management & Web-based Information System Provider Network Recruitment and Management Utilization Review Evaluation, Outcomes and Continuous Quality Improvement Financing Model - Case Rate Maryland Specific Supports & Functions of a Care Management Entity 11

12. Example of Governance/Management Structure State Interagency Body State Funding Pool Financer/ Payers Local Allocation County Alliance Purchaser Case Rate for each enrolled child • Care Management Entity – Lead Non Profit • Organize and manage provider network • Staff and manage child and family team process • Intensive care management • Utilization management • Quality assurance • Outcomes management /monitoring • Management Information System (tracks children, services, dollars) Provider Provider Provider Natural Supports Natural Supports 12 Pires, S. (1996). Contracted system management structure. Washington, DC: Human Service Collaborative.

13. Example: Board Policy Statement Addressing Cultural and Linguistic Competence BOARD POLICY STATEMENT The Governing Board of All Children System of Care, in recognition of the growing diversity in the population of children and youth needing behavioral health services, seeks to create and maintain a culturally responsive helping environment capable of comprehensively addressing the unique needs of children of color. Children of color have historically been under referred to treatment and specifically in Alden County. It is the responsibility of ACSC to not only make its services accessible to all, but to affirm by policy and action its commitment to children of all cultures. It is the policy of ACSC to develop and maintain: links with key referral sources in our state’s communities of color; standards for providing services to ethnically, culturally diverse children; a culturally competent work force, reflective of the cultural diversity of the service population; intake procedures, treatment planning, and therapeutic interventions which recognize, enhance and strengthen cultural identity, dignity, and esteem; a treatment milieu in which racism, stereotyping, bigotry and prejudices are inappropriate and not tolerated. 13 Adapted from: People of Color Leadership Institute and Day, P.A. Cultural Competence Materials for MSW Students, Staff, Faculty and the Community University of Minnesota, Duluth

14. Input/evaluation of key management Input/evaluation of quality of services and programs Local system of care input Resource allocation Service planning and implementation Policies and procedures Grievance and resolution procedures Examples of Types of Family/Youth Partnership in System Governance and Management 14 Conlan, L. (2003). Implementing family involvement. Burlington, VT: Vermont Federation of Families for Children’s Mental Health.

15. Governance & System Management Presented by Michelle Zabel, MSS Director, Maryland Child & Adolescent Innovations Institute, Mental Health Institute & Juvenile Justice Institute Division of Child & Adolescent Psychiatry, School of Medicine, University of Maryland, Baltimore

16. The Maryland Children’s Cabinet and the Governor’s Office for Children VISION • Children’s Cabinet: All Maryland’s children are successful in life. • Governor’s Office for Children: Maryland will achieve child well-being through interagency collaboration and state/local partnerships. MISSION • The Children’s Cabinet, led by the Executive Director of the Governor’s Office for Children (GOC), will develop and implement coordinated State policies to improve the health and welfare of children and families. The Children’s Cabinet will work collaboratively to create an integrated, community-based service delivery system for Maryland’s children, youth and families. Our mission is to promote the well being of Maryland’s children. COMPOSITION • The Secretaries of the Departments of Budget and Management, Disabilities, Health and Mental Hygiene, Human Resources, and Juvenile Services, and the State Superintendent of the Maryland State Department of Education. • Chaired by the Executive Director of the Governor’s Office for Children.

18. A Scenario for State and Local Governance Structures State Governance State Systems Management Local Governance Local Systems Management Family Support Organizations Individual Care Planning with Child and Family Teams: Care Management Entity (CME)

19. Purpose is to “ensure the implementation of a local interagency service delivery system for children, youth, and families.” (Human Services Article, Annotated Code of Maryland) Composed of: Public and private community representatives and, A senior representative or department head of the:  (i) local health department;  (ii) local office of the Department of Juvenile Services;  (iii) core service agency;  (iv) local school system; and  (v) local department of social services.  LMBs are tasked with: Strengthening the decision-making at the local level; Designing and implementing strategies that achieve clearly defined results for children, youth, and families as outlined in a local 5-year strategic plan; Maintaining accountability standards for locally agreed upon results for children, youth, and families; Influencing the allocation of resources across systems to accomplish desired results; Building local partnerships to coordinate children, youth and family services within the county to eliminate fragmentation and duplication of services; and, Creating an effective system of services, supports, and opportunities to improve outcomes for all children, youth and families. Local Management Boards Infrastructure

20. Key Functions Include: Care Authorization Provider Credentialing and Enrollment Billing/Reimbursement and Provider Payment Utilization Management Continuous Quality Improvement Outcomes Data Information Management Administrative Service Organization

21. A CME is a structure that serves as a “locus of accountability” for youth with complex needs and their families. Provide Supports to Youth and Families: Child Family Team Facilitation using Wraparound Service Delivery Model Care Coordination using Standardized Assessment Tools Care Monitoring and Review Peer Support Partners Provide System Level Functions: Information Management & Web-based Information System Provider Network Recruitment and Management Utilization Review of Service Use, Cost, and Effectiveness Evaluation and Continuous Quality Improvement Cross-System and Jurisdiction Financing Populations to Be Served: 1915(c) Psychiatric Residential Treatment Facilities (PRTF) Demonstration Project Medicaid Waiver SAMHSA funded SOC grants – MD CARES and Rural CARES Child Welfare’s Place Matters Group Home Diversion using Resource Coordinators Other Out-of-Home Diversion using Care Coordination Regional Care Management Entities Local System Management and Service Delivery Infrastructure

22. Wicomico County, MD System of Care Structure Local Management Board Family Partner- Ship Center SOC Community Advisory Board Care Management Entity Care Coordinators Family Partners 211 System (screening) Service Coordination/Systems Navigation - CANS Families and Youth Agencies/Court Adapted from Wicomico County, MD

23. Governance and System Management Bruce Strahl Technical Assistance Partnership

24. Great Governance Starts With Great Collaboration Collaboration Defined: A mutually beneficial relationship between two or more parties who work toward common goals by sharing responsibility,authority and accountability for achieving results

25. Critical Characteristics of SOC Governance • Balanced-true sharing of responsibility, power and authority • Inclusive-with significant and authentic decision making roles for all who desire a role • Broad-Many places available to be a part of decision making for family, youth state and community partners • Defined- Roles concise, clear and understandable • Simple

26. Governance Characteristics (continued) • Culturally and linguistically competent • Clear communications flow and work flow and easily explainable to all stakeholders with diagram • Efficient and effective • Clear roles and procedures for decision making • Responds quickly but also accommodates a more deliberate approach when needed

27. WG WG WG WG WG Coordinating Committee Odd Number Group 11-13-17-19 PD, PI, Community Leaders, Lead Family, Family Member, Youth, Policy Makers, Lead Evaluator • Full Partnership • Facilitator • Agenda • 2 Framed Major Challenges • Work Group Meet • Work Group (Some) Report Progress • Agency Pitch – Networking OK Broad Based Governance System • Role • Frame Major Strategic challenges to go to full partnership • Set agenda for full partnership meeting • Model SOC principles • Barrier busting • Conscience of SOC, Cultural competency, family inclusion, collaboration • Help the PD • Model Change • Do It 1st • High Standard of Care/Quality OK Memorandum of Agreement STAKEHOLDERS MEETING EVERY OTHER MONTH Send a Work Group Out Standing or Ad Hoc • Decisions • Broad SOC Community Strategy • Intake System • Social Marketing • Referrals to Community Services • Participation in Child & Family Teams • Family Involvement • Administrative Team • Grant Requirements • Grant Administration • Staffing • Budget • Quality

28. Family and Youth Involvement in Your Governance System • Where should Family and Youth be in your governance system? • Pair family members and pair youth • Prepare a welcome for them • Provide background information and meeting protocols to new families • More tips

29. The 7 Keys to Governance Success 1) A cross functional team including youth, families, required partners and community partners participate in the development of a broad based governance structure. 2) The broad based governance structure provides a variety of meaningful decision making opportunities for partners to participate and be involved in governance on the coordinating council, full partnership, work groups and administrative team.

30. 7 Keys (continued) 3) Diagrams and procedures exist of the governance structure and all partners have a clear understanding of how work and communications flow as well as how decisions are made. SOC decisions are not made outside of the agreed upon governance structure and process. 4) The governance structure reflects the cultural make up of the community and population served.

31. 7 Keys (continued) 5) An evident commitment exists to review and enhance the governance system at regular intervals using broad community and partnership involvement. 6) Orientation, preparation and education must be utilized for all partners for authentic and meaningful participation to take place in the governance system. 7) “Collective Will” is the most important ingredient. Without it, structures and processes will not work and can be manipulated but with it, structural challenges can be overcome.