Jacki Hoover, LSW Manager, Executive Office Allegheny County Department of Human Services

1. Improving Well-Being for Children Involved in Child WelfareThe 20th Annual NARA licensing seminar San Francisco, CASeptember 11, 2012 Jacki Hoover, LSW Manager, Executive Office Allegheny County Department of Human Services

2. CHCS Mission To improve health care quality for low-income children and adults, people with chronic illnesses and disabilities, frail elders, and racially and ethnically diverse populations experiencing disparities in care. Our Priorities Enhancing Access to and Coverage of Services Improving Quality and Reducing Racial and Ethnic Disparities Integrating Care for People with Complex and Special Needs Building Medicaid Leadership and Capacity 2

3. Child Health Quality Portfolio • Goal: Impact Policy and Practice • Children with Complex Needs • Children involved in Child Welfare • Children insured by Medicaid • Children with multi-system involvement • Topical Areas • Children’s Behavioral Health (25 States) • Children’s Oral Health (CA, NJ) • General Medicaid Issues (National)

4. Legislative Opportunities to Improve Health Care for Children in Foster Care Fostering Connections Act (2008) • Screening and assessment • Access to and monitoring of care • Coordination of care • Oversight of medication use Child Health Insurance Program Reauthorization Act (2009) • Parity for mental health and substance abuse services • Dental coverage for children without dental insurance

5. Legislative Opportunities to Improve Health Care for Children in Foster Care Patient Protection and Affordable Care Act (2010) • Medicaid coverage for youth aging out of foster care • Care teams to support patient centered medical homes • Maternal, Infant and Early Childhood Home Visiting Program • Transition planning • Dental coverage for children without dental insurance • Health information technology

6. Legislative Opportunities to Improve Health Care for Children in Foster Care Child and Family Services Improvement and Innovation Act (2011) • Requires protocols for effective use and monitoring of psychotropic medications in particular. • Requires state CW agencies to outline how they will respond to emotional trauma experienced by children in foster care. • Renews (2012-2014) the Secretary of Health and Human Services’ ability to authorize up to 10 demonstration projects, which includes applications with a focus on well-being.

7. Premise for our work… • Children in child welfare - specifically those in foster care - have significantly higher rates of physical, behavioral and oral health needs. • Foster children are at high risk for the negative consequences of poor access and uncoordinated care. • Children in foster care require a tailored approach to care delivery involving all system partners.

8. What does the Data Say?

9. Faces of Medicaid: Child Medicaid Behavioral Health Utilization and Expenditure Study • Forthcoming CHCS study funded by Annie E. Casey, SAMHSA, and the Commonwealth Fund • 2.8 million children (9.6%) in Medicaid in 2005 used a behavioral health service and/or psychotropic medications. • Among behavioral health service users, 56% used behavioral health services and no psychotropic medications, and 44% used behavioral health services and psychotropic medications. • Among psychotropic medication users, 29% (490,360) children used psychotropic medications with no other behavioral health service.

10. What about Children in Foster Care? • Representation • Foster children represented 3.2% of Medicaid children in 2005 • Service Utilization • Five times more likely to use behavioral health services relative to their proportion, representing 15% of service users • 23% of foster children had at least one claim for psychotropic medication • Among those using behavioral health care: • Mean behavioral health expenditures of $8,000 • Mean physical health expenditures of $4,000 • Mean total Medicaid expenditures (PH/BH) nearly 7 times that of the overall Medicaid child population* *per CMS Statistical Supplement, 2008

11. How can we impact health outcomes for children in child welfare?

12. Leverage Available Resources • Existing mandates • Legislation and regulations • State and agency policy • Existing infrastructure • Human resources • Financial resources • Standing committees • Community-based organizations • Memoranda of Understanding among agencies • Contractual arrangements

13. Why focus on managed care to improve care for children in child welfare? • 73% of Medicaid children are enrolled in managed care.1 • 35 states enroll foster children in Medicaid managed care.2 • Managed care organizations are under contract to provide services to Medicaid-insured children. • Managed care organizations have incentives, infrastructure, and networks that can be leveraged to improve care and outcomes. • CHCS has a quality improvement model designed for managed care organizations. Sources: 12010 Medicaid Managed Care Enrollment Report, CMS; 2Unpublished study, Center for Health Care Strategies, 2011.

14. What is a CHCS Quality Improvement Collaborative? • Multi-year, facilitated peer network designed around a particular clinical area or population. • Data-driven approach to improve clinical and administrative practices related to health care. • Intensive technical assistance vehicle, utilizing experts (professional and/or lived experience) in the clinical topic or special population, continuous quality improvement, family and youth engagement, and other relevant domains.

15. Child Welfare Quality Improvement Collaborative • Three-year quality improvement initiative • focused on improving three aspects of health care for children involved in child welfare: • Access to Care • Connecticut Behavioral Health Partnership • Magellan Behavioral Health of Florida • Mid Rogue Health Plan • Priority Partners Managed Care Organization • UPMC for You • Coordination of Care • Volunteer State Health Plan • Wraparound Milwaukee • Appropriate use of Psychotropic Medications • CareOregon • Massachusetts Behavioral Health Partnership

16. Case Study: UPMC for You and the Department of Human Services of Allegheny County’s Office of Children, Youth and Families

17. Department of Human Services (DHS) of Allegheny County Comprised of: • DHS Executive Office • Five Program Offices • Area Agency on Aging • Office of Behavioral Health • Office of Children, Youth and Families (OCYF) • Office of Community Services • Office of Intellectual Disabilities • Four Support Offices • Office of Administration • Office of Information Management • Office of Community Relations • Office of Data Analysis Research and Evaluation

18. Allegheny County: Current placement type by age: 5/18/12 This excludes non-paid placements and JPO

19. About UPMC for You • Affiliate of UPMC (University of Pittsburgh Medical Center) Health Plan • Medicaid Managed Care Organization in 24 counties in Pennsylvania, including Allegheny County (location of Pittsburgh) • Provide services physical health, drug, vision and dental coverage (behavioral health is a carve-out) • Membership: • 160,000+ members as of May 2012 • 65,000 (41%) members in Allegheny County – 39,000 are under 21 years old

20. UPMC for You Service Area

21. UPMC Insurance Services • UPMC for You is top 10 nationally and #1 in State for Medicaid quality • Fastest growing Medicaid plan • Fastest growing CHIP plan • Highest Commercial Satisfaction J.D. Power • 4 Star Medicare plan • Highest ranked provider satisfaction in PA

22. About Community Care Behavioral Health • Incorporated 1996 • Part of the UPMC Insurance Service Division • Non-profit & federally tax-exempt BH-MCO • 650,000+ HealthChoices members in Pennsylvania • Recently received a contract to provide services in 16 counties in New York • Largest not-for-profit behavioral health MCO in the country

23. Covered Behavioral Health Services • Psychiatric Inpatient • Inpatient Detoxification • Non Hospital Detox and Rehabilitation • Partial Hospital (MH and D&A) • Intensive Outpatient (MH and D&A) • Halfway House • Psychiatric Rehabilitation • Outpatient Therapy (MH and D&A) Clozaril Services • Methadone • Diversion and Acute Stabilization • Extended Acute Care Units • Residential Treatment Facility • BHRS (Children) • Family based • Multi-systemic Therapy • ICM/RC/Blended Case management • Community Treatment Team • Acute Case Management • Crisis Services • Peer Support

24. Project Background • Center for Health Care Strategies, Inc. (CHCS) grant received by UPMC for You • “Improving Outcomes for Children Involved in Child Welfare” • Joint venture between: • UPMC for You (UPMC Health Plan Medicaid plan) • Community Care Behavioral Health • Allegheny County Department of Human Services/Children, Youth and Families • Assistance/support from the Department of Public Welfare (DPW) and CHCS

25. Overall Goal Improve the coordination of physical & behavioral health care of children in foster care in Allegheny County and who have UPMC for You. • Children in foster care have an electronic health record created and sent to Allegheny County CYF. • Children in family foster care have an annual PCP visit. • Children in family foster care and over age three have an annual preventive dental visit. • Children (over 5) who are newly placed in foster care and are identified as having a need for a behavioral health service(s) then receive that behavioral health service(s) within sixty (60) days.

26. How It Works… • Implemented in February 2008 (planning began in March 2007) Weekly: • Receive membership file via FTP site from Allegheny County • Identify new & exiting population • Review each member’s history and assign primary care manager • Care manager completes a gaps in care form and mails to case worker at CYF – return envelop enclosed • If the care manager does not receive form in a few weeks, telephonic outreach occurs Monthly: Send electronic health record for new members Quarterly: Send electronic health record for all existing members

27. Roles for Partners Role of Case Worker • Work with UPMC for You and Community Care Behavioral Health care managers to obtain necessary services for the participating children • Foster Care Case Workers are able to contact UPMC for You and Community Care anytime regarding a member • Community Care has a dedicated phone line for the project • Primary contact for health plan care managers Role of Health Plan Care Manager • Assist with continuity of care – knowledge of child’s history • Provide additional community and health plan resources • Assist in obtaining appointments for physical or behavioral health services • Transportation assistance • Overall knowledge and guidance of services, conditions, resources, etc.

28. Initial Challenges and Solutions • Legal / HIPAA • What can be discussed between entities? • What can be included in the electronic health record? • Trained staff for all organizations on what can and cannot be shared • Member Identification • How do we identify members in a timely and accurate way? • Project Commitment • Obtaining commitment from all entities • Creating and understanding goals and processes • Education and communication to staff • Persistence and education were crucial to gain the child welfare case worker’s understanding and participation

29. Initial Challenges and Solutions • Health Plan Outreach to Foster Parents Directly • Legally this was a challenge • The inability to contact the member (foster parent) directly posed a challenge to coordinate care and ensure gaps in care are met • We coordinated services through the county case worker • Identification of Primary Contacts • Creation of a close relationship between care managers / supervisors of UPMC for You and Community Care was important for success • Established a few key stakeholders versus incorporating a large group in the everyday processes of the project • Weekly contact among organizations • Communication and Language • Understanding the organizational structure and language of the county • Target problems • Strategic invitations • High Risk (trauma) • Support and resilience

30. Continual Quality and Process Improvement Staff • Early educational and training …then staff re-education • Incentives • Gift cards, breakfast, outreach and Kudo’s Information Technology • Improve accuracy of data • Integration of electronic health record into the Allegheny County IT system Process Improvement • Develop training procedures and policies to reduce lag time • What is HIPAA vs. organizational culture • Changes to communication strategy – implementation of mailed gaps in care list (blue form)

31. Training Brochure for New Staff

32. Results for Aim #1: Create an electronic health record for 100% of the target population and send the record to Children, Youth and Families. Note: The electronic health record was a new initiative for the pilot.

33. Electronic Health Record from a Caseworkers POV Electronic health record from UPMC for You on each child • Provide child’s history, current treatments and treatment needs • Updated providers and medication • Snapshot and direction to move forward • Planning tool • Accessible to parents

35. Electronic Health Record (cont.)

36. Results for Aim #2: Ensure the target population has a 10 percentage point improvement of the baseline data for an annual well child visit. There is a statistical significance between baseline and year 1! Note: The child had to be in placement with UPMC for You insurance for 12 months.

37. Results for Aim #3: Ensure the target population has a 10 percentage point improvement of the baseline data for an annual dental visit. Note: The child had to be in placement with UPMC for You insurance for 12 months and are 3 years or older.

38. Results for Aim #4: Ensure children (over 5) newly placed in family foster care and identified by Children, Youth and Families as needing a behavioral health service receives a behavioral health service increases by ten percentage points. Note: The child had to be in placement with UPMC for You insurance for 60 days and over the age of 5 due to services rendered by the Alliance for Infants.

39. Other Benefits:Beyond Physical Health Care Benefits from Allegheny County’s New Relationship with Community Care Behavioral Health (CCBH) • CCBH Help Address: • Related fear and anxiety • Needs related to the trauma of separation • Underlying issues related to the need for substitute care • Help access an array of services in a timely manner that may prevent longer-term problems as well as alleviate the pain of traumatic adjustments • Provide support in the reunification process • Crisis intervention • Screening • Long-term support • CCBH Developed a dedicated line for the pilot project

40. Other Benefits to Allegheny County DHS • Updated OCYF physical health exam to include questions regarding behavioral health • Better communication upon child’s discharge from hospitals • Less subjectivity to fall on CYF caseworkers • Receive assistance in maintaining continuity of care for children who have existing services

41. What’s Next? • Working with the Allegheny Office of Disability and Southwest PA Health Care Quality Unit to provide electronic health records for UPMC for You (Medicaid) and UPMC for Life Specialty Plan (dual-eligible) members • The Southwest PA Health Care Quality Unit is to use e-health record data to coordinate care for members of the UPMC for You and UPMC for Life Specialty Plans who have intellectual disabilities and to coordinate their care, including non-health related services, with the Office of Intellectual Disabilities of the County of Allegheny through Intensive Services Coordinators.

42. Contact Information Jacki Hoover Program Manager Allegheny County Department of Human Services Phone: (412) 350-5799 Email: Jacki.Hoover@alleghenycounty.us