Study on State Strategies for Expanding Systems of Care

1. Study on State Strategies for Expanding Systems of Care National Evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program CCC Meeting – March 2, 2011 Beth A. Stroul, M.Ed. Robert M. Friedman, Ph.D.

2. Background • SOC concept introduced in mid 1980s as part of CASSP (Child and Adolescent Service System Program) funded by NIMH • Concept included a set of values and principles and a general approach to serving children with serious emotional challenges and their families • Emphasis on individualized and family-driven care; strength-based care in home and community; cultural and linguistic competence; interagency collaboration; and alignment of policy, principles, and practice

3. Background • All states received CASSP grants to enhance capacity to develop and implement SOCs – funds for capacity-building, not direct services • Other initiatives to support SOCs – block grant requirements, class action lawsuits, and new programs of private foundations • With CASSP phase out, the CMHI (Children’s Mental Health Initiative) was launched in 1993 • Provides funds to communities, states, tribes and territories to reform their systems in accordance with the SOC approach and to build service capacity

4. Background • Implicit goal of the CMHI – to use the time-limited demonstration grants and accompanying TA and evaluation to produce system change that will be maintained after grants end and will have a statewide impact • In 2002, a study was initiated to determine the success of grantees in sustaining their SOC infrastructure and services post grant and to identify strategies for accomplishing this • Identified effective sustainability strategies were and explored the role of states in sustainability

5. Background • In 2008, a CCC workgroup was created to focus on bringing SOCs to scale—essentially expanding them statewide • Through CMHI national evaluation, a study was initiated in 2009 to explore strategies to expand SOCs statewide in states that have made progress toward statewide system development • This presentation is a report of the methods used in this study, the findings, and preliminary conclusions

6. Study Method • Phase 1: Develop a conceptual framework to guide the study • Phase 2: Select a sample of 9 states that have made significant progress in sustaining and expanding SOCs to study • Phase 3: Contact state director of children’s mental health in these states and jointly identify key informants to interview • Phase 4: Develop semi-structured interview protocol based on conceptual framework and use it to gather data from informants via phone interviews

7. Study Method • Phase 5: Gather additional information from interviewees on strategies they believed to be most important • Phase 6: Prepare summary report of each state • Phase 7: Review findings from each state and develop preliminary overall conclusions • Phase 8: Share preliminary conclusions with panel of experts to assist in interpreting findings and determining implications • Phase 9: Prepare report and TA resources and disseminate findings

8. Site Selection • Step 1: Nomination of states for inclusion by group of knowledgeable individuals who work in multiple states • Step 2: Conduct screening interview with state children’s mental health director to obtain additional information • Step 3: Selection of 9 states based on information and considerations of geographic and demographic diversity

9. A Caveat • Not an independent evaluation to document the outcomes of these states’ SOCs • Focus on identifying strategies they used and the effectiveness of these strategies as judged by key informants • Other states could have been included, but study was limited to a sample of 9 and we sought diversity in the sample

10. States in Study Sample New Jersey North Carolina Oklahoma Rhode Island • Arizona • Hawaii • Maine • Maryland • Michigan

11. State Characteristics

12. SOC Grants in States • 30 Total Grants • 13 State • 13 Local • 4 Tribal

13. Individuals Interviewed

14. Expanding What?Elements of Systems of Care

15. Strategic Framework: Roadmap for System Change • Implementing Policy, Administrative, Regulatory Changes • Developing or Expanding Services and Supports, Care Management, and Individualized Approach • Providing Training, TA, and Coaching • Generating Support and an Advocacy Base • Creating or Improving Financing Strategies

16. Implementing Policy and Regulatory Changes

17. Strategies Infusing and “institutionalizing” SOC approach • Creating an ongoing focal point of accountability at the state and local levels • Developing and implementing strategic plans • Strengthening interagency partnerships for coordination and financing • Enacting legislation • Promulgating rules, regulations, standards • Incorporating in RFPs and contracts • Incorporating in monitoring protocols

18. Findings Most Effective Strategies Across States • Creating a locus of accountability for SOCs at state and local levels • Developing a strategic plan – formal or informal • Requiring SOC approach in RFPs, contracts, regulations, and standards Emerging or Neglected Strategies • Incorporating SOC approach into monitoring protocols

19. Establish Locus of Accountability & Management New Jersey: • State – Div. of Child Behavioral Health Services, Dept. of Children and Families and Contracted Systems Administrator as an Administrative Services Organization • Local – Care Management Organization (CMO) in each region for accountability and care management for high-need children Oklahoma: • State – OK Dept. of MH and SA Services • Local – Local multi-sector coalitions

20. Establish Locus of Accountability & Management Arizona: • State – Children’s SOC Office, Div. of Behavioral Health Services, Dept. of Health Services • Local – Regional Behavioral Health Authorities Maryland: • State – Children’s Cabinet Governor’s Level and Office of Child and Adolescent Services, Mental Hygiene Admin. • Local – Local Management Boards and Regional Care Management Entities for high-need children Maine • State – State Dept. of HHS • Local – 3 regional collaboratives staffed by state regional leaders (government)

21. Develop & Implement a Strategic Plan Hawaii: • 4-year strategic plan for children’s MH required by legislature • Priorities for 2007 – 2010 were to increase access to care, practice development program, financial plan • Includes thresholds, benchmarks • Maryland: • Blueprint for Children’s Mental Health, Children’s Cabinet • Oklahoma: • Action plans and logic models (not called “strategic plan”) • Local plans required

22. Promulgate Rules, Regulations, Standards, Guidelines, Practice Protocols Maryland: • SOC language is in Medicaid and Mental Hygiene Admin. regulations New Jersey: • Practice manual based on SOC approach Michigan: • Adopted family-driven, youth-guided policy Arizona: • Provider manual and practice protocols

23. Incorporate SOC Approach in Contracts New Jersey: • Required by contracts with RHBAs and providers to align with SOC goals and demonstrate with performance measures Maryland: • SOC approach reflected in contracts with CMEs Michigan: • Required in contracts with prepaid health plans (MCOs) and community MH agencies Oklahoma: • SOC approach required in RFPs and contracts with local coalitions and their contracts with providers

24. Developing or Expanding Services and Supports

25. Strategies • Creating a Broad Array of Effective, Individualized, Coordinated Home and Community-Based Services and Supports • Creating or expanding array of services and supports • Creating or expanding care management • Creating or expanding individualized approach • Expanding family and youth involvement • Creating or expanding evidence-informed services • Creating or expanding provider network • Improving cultural/linguistic competence of services • Reducing disparities

26. Findings Most Effective Strategies • Creating a broad array of services and supports – adding nontraditional home and community-based services and supports • Implementing an individualized, “wraparound” approach to service delivery – operationalizes the SOC approach at the service level Emerging or Neglected Strategies • Expanding the use of evidence-informed and promising practices • Creating “care management entities” to manage and coordinate care for high-need youth and their families

27. Create or Expand Array of Services Michigan: • Incorporated broad array into Medicaid – wraparound, home-based, respite, peer-to-peer, community living supports, infant MH, etc. New Jersey: • Expanded array to include mobile crisis response, in-home, behavioral supports, TFC, mentoring, flex funds, family support, etc. Arizona: • Direct support services covered within capitation Maine: • Incorporated broad array of community based services, care management, trauma-focused services, family partners, etc.

28. Create or Expand Individualized Approach • Arizona: • Child and family teams (CFTs) implemented for all children, more extensive for children with complex needs • New Jersey: • All CMOs use wraparound approach to engage, plan, and deliver services • Michigan: • Wraparound critical building block, embodies SOC principles in services • Maine: • Implemented Wraparound Maine • Oklahoma: • Wraparound is major part of strategy for high-need, high-cost youth

29. Providing Training, TA, and Coaching

30. Strategies • Preparing Skilled Providers to Provide Effective Services and Supports in SOCs • Providing training and TA on SOC philosophy and approach • Providing training, TA, and coaching on effective services • Creating the capacity for ongoing training and TA on SOCs and effective services

31. Findings Most EffectiveStrategies • Providing ongoing training, TA, and coaching on SOC approach • Creating the capacity for ongoing training and TA on SOC approach Neglected or Emerging Strategies • Providing ongoing training on evidence-informed and promising practices

32. Provide Ongoing Training on SOC Approach and Develop Training Capacity New Jersey: • Statewide training institute at Univ. of Medicine and Dentistry of NJ • Regional and county training for CMOs and providers on SOC philosophy • Statewide wraparound training and coaching • Care manager training Maryland: • Innovations Institute at Univ. of Maryland • Virtual website training center • Training and coaching statewide • Wraparound certification program under development

33. Provide Ongoing Training on SOC Approach and Develop Training Capacity Oklahoma: • Annual training and wraparound training plus coaching North Carolina: • Collaborated with universities to provide training and current SOC grant • State-level collaborative has training committee Michigan: • Skilled local community MH agencies train Maine: • SOC community provides training

34. Generating Support and an Advocacy Base

35. Strategies • Generating Support from Key Stakeholders and High-Level Decision Makers • Establishing strong family and youth organizations • Cultivating partnerships with key stakeholders (e.g., provider agencies, MCOs) • Generating support among high-level administrators and policy makers • Using data on outcomes and cost avoidance to “make the case” for expanding SOCs • Creating an advocacy base through social marketing • Cultivating leaders

36. Findings Most Effective Strategies • Establishing a strong family organization to advocate, support, and be involved in expanding SOCs • Generating policy-level support among high-level administrators and decision makers at the state level Emerging or Neglected Strategies • Establishing a strong youth organization • Using data on outcomes and cost avoidance to make the case for expansion

37. Establish a Strong Family Organization New Jersey: • Contract with NJ Alliance of Family Organizations • Family Support Organizations (FSOs) in counties Maryland: • Contract with MD Coalition of Families for Children’s MH which has been critical to survive changes in administration Arizona: • Contract with Family Involvement Center and MIKID • FIC is Medicaid provider of family support services Hawaii: • $800 K contract with HI Families as Allies North Carolina: • Uses Block Grant funds to support family organization Role is to policy participation and advocacy in system expansion efforts plus family and peer-to-peer support, training, etc.

38. Establish a Strong Youth Organization New Jersey: • Each FSO houses a youth partnership Michigan: • Funds a community MH agency in Detroit to support a youth organization Arizona: • Funds youth advocates through contracts with family organizations Hawaii: • New youth organization embedded in family organization Maine • Strong Youth MOVE

39. Generate Support Among High-Level Decision Makers High-Level Administrators, Policy Makers, and Decision Makers at State and Local Levels New Jersey: • Strong support for expansion from Governor’s Office and MH Commissioner Michigan: • Brought high-level decision makers to national SOC meetings, Policy Academies Maryland: • Work with agency executives through Children’s Cabinet Oklahoma: • Support from all Commissioners has been critical

40. Use Outcome Data to “Make the Case” Michigan: • Outcome data available by individual children, caseloads, agencies, statewide • Web-based CAFAS used by all community MH agencies – provides immediate feedback for management, QI, and to support expansion Oklahoma: • Use of data with legislature has been highly effective • University of Oklahoma involved in evaluation

41. Use Cost Avoidance Data to “Make the Case” Data on Cost Avoidance or Comparison with High-Cost Services Michigan: • Data from SOCs used to demonstrate prevention of out-of-home placements in CW and cost avoidance Oklahoma: • Data has been used on reduction in out-of-home care and translated into financial implications

42. Developing or Improving Financing Strategies

43. Strategies • Creating Long-Term Financing Mechanisms for SOC Infrastructure, Services, and Supports • Increasing ability to use Medicaid financing • Obtaining new or increased state MH funds • Obtaining new or increased funds from other child-serving systems • Blending or braiding funds across systems • Redeploying funds • Obtaining new or increased local funds • Increasing use of other federal entitlements • Obtaining federal grants

44. Findings Most Effective Strategies Increasing ability to obtain Medicaid financing – waivers, adding new services, changing existing definitions, using rehab option, etc. Emerging or Neglected Strategies Redeploying funds from higher cost to lower cost services Obtaining, braiding, or blending funds with other child-serving systems

45. Increase the Use of Medicaid Cover an Extensive Array of Services and Supports in State Medicaid Plans in Addition to Traditional Services – New Services, Revised Definitions Arizona, New Jersey, Michigan, Maryland, Hawaii, Maine: • Intensive home-based, intensive outpatient substance abuse, respite, family and peer support, treatment planning, wraparound process, therapeutic foster care, supported housing and employment, mobile crisis response, crisis stabilization, behavioral aides, skills training, traditional Native health, EBPs, ACT teams, targeted care management

46. Increase the Use of Medicaid Use Multiple Medicaid Strategies to Expand Covered Populations and Home and Community-based Services Michigan: • 1915(b) Managed Care Specialty Supports & Services Waiver; 1915(c) Home & Community-Based SED Waiver; 1915(c) Children’s Waiver; 1915(c) Habilitation Supports Waiver, Clinic; Rehab; Targeted Case Management; Psych Under 21; EPSDT; Family of One North Carolina: • Rehab option, expanded coverage, revised service definitions Arizona: • System is primarily Medicaid funded

47. Increase the Use of Medicaid Generate Medicaid Match by Using Funds from Both Mental Health and Other Child-serving Systems New Jersey: • Pools funds across MH, CW, and Medicaid to make services match-able (included RTCs and group home resources) • Brought in $30 m in state offsets Michigan: • CW funds blended with BH have created Medicaid match and expanded resources for services outside of capitation

48. Increasing the Use of Funds from Partner Child-Serving Systems Obtain New or Increased Funds and/or Braid, Pool Funds Maryland: • Pools funds across systems through Children’s Cabinet • Slots in CMEs for children in CW and JJ, JJ funds MST • CFTs eligible for funds from partner agencies Michigan: • Joint initiative with CW blending with BH, redirecting funds to home and community-based services for children needing intensive services • Pilot in 8 urban counties, will be statewide Maine: • CW provides funds for Wraparound Maine • Start-up funds from JJ for MST, FFT, MTFC

49. Redeploy Funds Arizona: • Promoted use of home and community-based, direct support and rehab services resulting in decreased utilization of residential (1115 waiver) Maryland: • Child welfare funds redirected and blended with MH funds to draw down additional Medicaid funds Michigan: • Residential not covered in BH system, but extensive use in CW. New pilot to divert or discharge from RTCs with full array of intensive, community-based services Maine: • Decrease in residential population used to fund Wraparound Maine

50. Roles of SOC Communities in Expansion Efforts