Promoting the Well-Being of Children in Foster Care: The Role of Medicaid Sheila A. Pires

1. Three Branch Institute on Child Social and Emotional Well-Being: Meeting for State Teams Promoting the Well-Being of Children in Foster Care: The Role of Medicaid Sheila A. Pires Human Service Collaborative July 25, 2013 Philadelphia, PA

2. Why Medicaid is Essential • Most children in foster care are Medicaid-eligible • Most children remain eligible for Medicaid when • they leave foster care • WI study – 85% remain eligible • Child welfare was not intended to be a health or • behavioral health care delivery system

3. Children in Foster Care Are a High Cost Medicaid Population • Represent 3.2% of children in Medicaid but 15% of children • using behavioral health services • Have the highest penetration rate for use of behavioral • health services than any other aid category of children • (32% of children in foster care use behavioral health services • compared to 26% of children on SSI, and 4.9% TANF) • Have the highest mean behavioral health expenditures of any • aid category of children ($8,094 per child compared to $7,264 for • children on SSI) • Have overall Medicaid mean expenditures (physical and behavioral • health care) of $12,130 per child – costs are driven by behavioral health care • Children in foster care who use behavioral health services have costs that • are 7x higher than for Medicaid children in general Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid: Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ; Center for Health Care Strategies

4. Children in Foster Care Use More Restrictive, More Expensive Services in Medicaid • More likely to use: inpatient psychiatric services, • residential treatment and therapeutic group care, emergency • room services, and psychotropic medications • Children in foster care are only one-fifth the size of the • TANF population but use nearly the same amount of dollars • for residential and group care and ER visits and 3.5 times • more for therapeutic foster care Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid: Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ; Center for Health Care Strategies

5. Children in Foster Care Have High Rates of Psychotropic Medication Use • Are 3.2% of Medicaid child population, but nearly 13% of • Medicaid children using psychotropic medications • 23% of children in foster care use psychotropic medications • paid for by Medicaid (compared to 27% of children on SSI and • 4% of TANF children) • Are more likely to receive 2 or more concurrent psychotropic • medications than other aid categories of children (49% FC, • 46% SSI, 26% TANF) • Of children getting anti-psychotics, 42% are in foster care • (42% are on SSI, 18% are TANF) • Have highest mean expenditures for psychotropic medications of any aid • category of children ($934 FC, $916 SSI, $475 TANF) Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid: Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ; Center for Health Care Strategies

6. Health Reform • Renewed interest in: • Managing care for populations with • chronic conditions • Intensive care coordination models • Managing the total cost of care • Moving dollars from “deep end” to • home and community based • Evidence-informed approaches • Data-informed approaches • Use of technology • “Integrated” care through capitated managed care Pires, S. 2011. Washington DC: Human Service Collaborative

7. Medicaid Re-Design and Integration Caveats • Our experience has been that – • When physical and behavioral health dollars are integrated, • there is a risk of behavioral health dollars being absorbed by • physical health services • When adult and child behavioral health dollars are • integrated, there is a risk of child behavioral health dollars • being absorbed by adult services • This occurs in the absence of appropriate customization. Pires, S. 2011. Washington DC: Human Service Collaborative

8. Customization within Medicaid Adds Value for Children in Foster Care • Regardless of Medicaid managed care design (integrated, carve out), • certain design elements and contractual specifications enhance • value for foster care population • See virtually all of these elements/specs looking across the states • but not all in any one state (has been incremental process) • Tend to see more in states with behavioral health carve outs than • integrated designs • Documented initially in 10-year Health Care Reform Tracking Project • (1997-2003) • Examples in “Making Medicaid Work for Children in Child Welfare” (2013)

9. A word about a “special benefit” for foster care population through a foster care carve out – • TANF and SSI-enrolled children need the same service array as foster care population (while prevalence rate for behavioral health is higher for children in foster care than TANF population, there are many more TANF children) • Children don’t stay in foster care forever (median LOS in 2011 was 13.2 mos.) but tend to remain Medicaid-eligible and in need of services • Can lead to unintended consequence of parents having to relinquish custody to access care (especially an issue for children with serious behavioral health challenges)

10. Service Coverage: • Change the Trajectory of High End Service Use • Cover a broad array of behavioral health in-home and • community-based services (May 7, 2013 CMCS and SAMHSA • Informational Bulletin) • AZ: In-home services; respite; life skills training; family and • youth peer support; therapeutic foster care; case management; • supported housing; supported employment; mobile crisis • intervention; crisis stabilization; transportation; Wraparound • process • MA: In-home services; family peer support; mobile response; • therapeutic mentoring; behavior management therapy and • behavior therapy monitoring; intensive care coordination using • a Wraparound approach • NJ: Mobile response and stabilization; therapeutic group home care; • treatment homes/therapeutic foster care; intensive care management; • Wraparound process; behavioral assistance; intensive in-home/community • services; transportation; youth support and development

11. Service Coverage: • Change the Trajectory of Use of Inappropriate Care • Cover evidence-based practices (May 7, 2013 CMCS and • SAMHSA Informational Bulletin) • e.g. Trauma-Focused Cognitive Behavioral Therapy • Multisystemic Therapy, Functional Family Therapy, • Multidimensional Treatment Foster Care, • Parent-Child Interaction Therapy, • Integrated Co-Occurring Treatment • Dollars needed for training, capacity-building, quality • and fidelity monitoring

12. Trauma-Informed EPSDT Screening and Early Intervention: • Change the Trajectory of High End Service Use • (3/27/13 CMCS and SAMHSA Informational Bulletin and 7/11/13 SMD Letter) • Incorporate state child welfare requirements for physical, • behavioral and dental health screens within specified • timeframes • AZ: Urgent response requiring behavioral health • screen within 72 hrs of entering care and “fast track” • linkage to services • Mandate use of standardized screening tools and inclusion • of behavioral and developmental (not only physical health) screens • MA: Enhanced screening rate • Require inter-periodic screens when child enters foster care, or • changes placement, or tied to length of stay in foster care

13. Psychotropic Medications: • Change the Trajectory of Inappropriate Use • (August 24, 2012 CMCS Informational Bulletin and November 23, 2011 • Tri-Agency Letter) • Track and monitor outlier use, e.g. too young, too many, • too much, (growing number of states) – • interface with Drug Utilization Review Board • Consultation to prescribers, including primary • care providers (MA, VT) • Orient MCOs to state’s informed consent and assent • policies in child welfare • Provide coverage and training for treatment alternatives • (aggression, sleep disorders)

14. Primary Care: Medical Home • Every child has an identified primary care provider • Annual well-child visit • Metabolic monitoring if on psychotropic medications • Asthma protocols • Electronic health record – health passport

15. Analysis of Medical Home Services for Children with Significant Behavioral Health Conditions “All behavioral health conditions except ADHD associated with difficulties accessing specialty care through medical home” “The data suggest that the reason why services received by children and youth with behavioral health conditions are not consistent with the medical home model has more to do with difficulty in accessing specialty care than with accessing quality primary care”.* • Need for more intensive care coordination approaches for • children with significant behavioral health conditions *Sheldrick, RC & Perrin, EC. “Medical home services for children with behavioral health conditions”. Journal of Developmental Pediatrics, 2010 Feb-Mar 31 (2) 92-9

16. Medicaid-Related Opportunities/Challenges in the Affordable Care Act • Coverage of young adults in foster care to age 26 (2014) • Addiction and mental health treatment accounted for 42% of hospital claims • for 19-25 year olds enrolled in their parents’ health plans in 2011 through ACA • (Employee Benefit Research Institute, April 2013) • 1915 i home and community-based services (less • stringent than institutional level of care criteria of 1915 c • home and community-based waiver) • Section 2703 Health Homes (“chronic conditions” can • include significant behavioral health challenges; cannot • limit by age, but can customize approach for children)

17. For Family Members Who Are Not Medicaid-Eligible • Access to insurance coverage through Health • Exchanges • Elimination of annual and lifetime limits on benefits • No denial of coverage for pre-existing conditions • No cost-sharing/co-pays for certain preventive services • (based on IOM recommendations; important for Medicaid populations as well) • Well-woman visits • Gestational diabetes screening • HPV DNA testing • Counseling for sexually transmitted infections • HIV screening and counseling • Contraception and contraceptive counseling • Breastfeeding support, supplies and counseling • Interpersonal and domestic violence screening and counseling

18. Lessons from States: Customization • for Children in Foster Care in Medicaid • Medicaid service delivery and payment models need to reflect attention to state child welfare, Medicaid and behavioral health system policies and goals – • Collaborative planning, design, implementation needed • Explore potential for Medicaid match from child welfare – • most children are Medicaid eligible; many services paid for by • child welfare are Medicaid-allowable (NJ, AZ, MI) • State agencies need to approach implementation in partnership with managed care entities

19. Example: Addressing Parental Substance Abuse • Medicaid • Cover substance use disorder services (adults who are eligible • for Medicaid can access) • Cover evidence-informed interventions for Medicaid child that • incorporate family engagement, education and support • Cover 1:1 crisis stabilizers for child (WI) • Cover family and youth peer support • Child welfare • IV-E waiver (for adults who are not Medicaid-eligible and for • non-Medicaid covered services) • Mental Health and Substance Abuse • May manage Medicaid match for BH services • Block grant funding for adults not Medicaid-eligible or services • not covered by Medicaid

20. 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 Re-Design Alternative to detention-high cost/poor outcomes Alternative to out-of-school placements, high special ed costs Juvenile Justice Education 20 Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

21. Illustrating the Impact of State Efforts: Jacob and Jeremy* At 12, Jacob was removed from his father’s home due to neglect and was placed with an aunt in another town. Jacob began using drugs and skipping school. His aunt talked to her child welfare case worker about getting Jacob substance abuse counseling and also thought that a male adult mentor would be good for him. However, traditional Medicaid did not cover substance abuse services or therapeutic mentors, and the child welfare system’s budget had been cut, making access to these services through child welfare also difficult. Jacob became increasingly angry and aggressive toward his aunt, and after threatening her with a knife, was held at the juvenile detention center. While there, Jacob attempted suicide. He was hospitalized in an adolescent psychiatric unit for a week, placed on psychotropic medications, and discharged to a residential treatment center after his aunt refused to take him back without community-based services. Jacob remained in the residential facility for nine months, and was then discharged to a foster home. The one-year cost of his detention, hospitalization, medications and residential stay totaled $67,900, $48,000 of which was paid for by Medicaid. Contrast Jacob’s story with that of Jeremy, also removed from home at age 12 and placed with a relative, and having a similar history of substance use, skipping school, anger, aggression, and alternating threats to kill his grandmother or himself. Jeremy, however, was enrolled in a Medicaid waiver program allowing access to substance abuse treatment, therapeutic mentoring, and a Wraparound process that provided him with a care coordinator and his grandmother with a family partner to provide peer support. They were both involved in a structured, strengths-based Wraparound process to find community-based approaches and solutions to the problems Jeremy was experiencing. The waiver services Jeremy and his grandmother received over the course of a year – therapeutic mentoring, substance abuse counseling, and Trauma-Focused Cognitive Behavioral Therapy for Jeremy, family peer support for his grandmother, care coordination, and use of a small amount of flexible funds to pay for a boxing gym membership paid for by child welfare totaled $21,740 in costs to Medicaid. Jeremy remains in the community with his grandmother. *Note. These are not actual case vignettes; they are representative to illustrate the differences for children as a result of state efforts to strengthen Medicaid for children in child welfare.

22. Federal Medicaid Guidance 7/11/13 State Medicaid Director’s Tri-Agency Letter on Trauma-Informed Treatment http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-07-11.pdf 5/7/13 Informational Bulletin on Coverage of Behavioral Health Services for Children, Youth and Young Adults with Significant Mental Health Conditions http://www.medicaid.gov/federal-policy-guidance/downloads/CIB-05-07-2013.pdf 3/27/13 Informational Bulletin on Prevention and Early Identification of Mental Health and Substance use Conditions http://www.medicaid.gov/federal-policy-guidance/downloads/CIB-03-27-2013.pdf 8/24/12 Informational Bulletin on Resources Strengthening the Management of Psychotropic Medications for Vulnerable Populations http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-08-24-12.pdf 11/21/11 State Medicaid Directors Tri-Agency Letter on Appropriate Use of Psychotropic Medications Among Children in Foster Care http://www.medicaid.gov/federal-policy-guidance/downloads/SMD-11-23-11.pdf

23. Resources Making Medicaid Work for Children in Child Welfare: Examples from the Field http://www.chcs.org/usr_doc/Making_Medicaid_Work.pdf Customizing Health Homes for Children with Serious Behavioral Health Challenges http://www.chcs.org/usr_doc/Customizing_Health_Homes_for_Children_with_Serious_BH_Challenges_-_SPires.pdf Psychotropic Medications Quality Improvement Collaborative: Improving the Use of Psychotropic Medications Among Children in Foster Care http://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1261326 CHIPRA Care Management Entity Quality Collaborative http://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1250388

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