RWJ Cross Systems Financing Strategies

1. RWJ Cross Systems Financing Strategies City of Philadelphia Division of Social Services Department of Behavioral Health/Mental Retardation Services Department of Human Services

2. The Premise • The City of Philadelphia Division of Social Services identified the issue that it was difficult to develop a continuum of care for all children (insured, underinsured and uninsured) due to the limitations and requirements attached to funding streams. • Despite multiple Federal and State funding streams there was a disparity in that insured children and youth received the benefit of services where children that were uninsured and underinsured did not.

3. Proposed Strategy • To identify the target population groups: • Children who need alternative living environments post treatment as opposed to RTF or group home placement. • Aging out adolescents who need behavioral health supports during transition to life in the community. • Children who could benefit from less restrictive settings when discharged from highly structured programs. • Children and adolescents in residential treatment, receiving services and supports through two or more systems of care within the Division of Social Services.

4. Proposed Strategy (continued) • To assess current levels of of care within DBH/MRS and DHS by conducting a clinical review of a random sample of children and youth in the following programs. • DBH/MRS • Residential Treatment Facility (RTF) • Residential Drug and Alcohol Long Term Treatment (3C) • Community Residential Host Home • DHS • Therapeutic Foster Care • Group Homes

5. Support for the Project • The Blue Ribbon Commission • The City of Philadelphia Government • Mayor • City Council • Directors/Commissioners within the Division of Social Services • Families/Consumers • The Judiciary • Pennsylvania Department of Public Welfare • Provider Organizations • School District

6. Key Products and Deliverables • Try to obtain Medicaid Waivers that allows us to: • Have greater flexibility in implementing a more creative and flexible continuum of care and natural supports that typically were not funded before. • Redefine populations more expansively that allowed DBH/MRS and DHS to fund services to a larger cohort of children and youth. • Allowed us to take traditional licensed services and make them more accessible and appropriate to the needs of the children and youth;e.g. mobile therapy through the Outpatient Level of care.

7. Key Deliverables (continued) • Reduced the number of youth in residential treatment by 25%. • Created alternatives for Aging Out Youth such as development of or expansion of supported/ independent living programs. • Increased access to services for uninsured and underinsured children by 30%. • Development of best practice standards for evaluation, treatment and outcome measures. • Developed new alternative resources and services to “wrap around” children and youth as a diversion to and a step-down from high levels of care.

8. Key Products: Why Were They Useful • The Waivers would allow us to provide access for children and youth that otherwise would have not received the services due to their eligibility status. • The creation of alternatives as a result of redirecting funds and blending funds has provided solutions we knew were much more effective and appropriate but were not fundable in the past. • The strong leadership, the integration of the funding streams, and the integration of staff and resources, made it more possible to achieve our goals.

9. Key Products: Why Were They Useful • Outpatient waiver was submitted to allow therapy to be mobile, not site-based, reaching more children and families that often did not access or could access traditional outpatient services. • Alternative funding allowed for the development of 16 crisis stabilization beds and 12 respite beds gave us alternatives to divert children and youth from inpatient treatment that didn’t require that level of care.

12. Beginning the Process • To begin addressing the financing question, the DSS Leadership determined that an assessment of funding streams had to be completed to identify: • Eligibility requirements attached to the funding streams • Categories of clients that were defined by the respective funding streams • The actual needs of children and youth served by both the Department of Behavioral Health and the Department of Human Services. • The Leadership also recognized that the Division of Social Services and its components are rich in resources, despite limitations and requirements attached to those resources

13. Beginning the Process • There was also the recognition that there has been and continues to be the integration of leadership, infrastructure and resources (where possible) that represented a “platform” for creating, redefining or redirecting resources more effectively and efficiently. • The support of the City and State governmental agencies including the Mayor, City Council and the Secretary of the Department of Welfare has been a strength and strong force in reshaping social services in Philadelphia.

14. Proposed Strategy • To initiate a review of all the funding streams to determine: • Eligibility and funding requirements • If the funding streams was being used effectively and efficiently across DBH and DHS. • To determine who pays for what services and how much, as well as who gets served and who does not.

15. Proposed Strategy (continued) • The Clinical Review will help us to: • Really define the clinical and supportive needs of children and youth that could be used to either divert from high levels of care or discharge to lower levels of care and/or family. • Most of identified needs and supports are anecdotal given the nature of our work; e.g. authorization, case management, etc.

16. Goal • Target state general funds for the development of early intervention and prevention services. • Reduce funding “silos” to increase expansion of funding streams to strengthen community-based services. • Develop a network of funding streams with a single contracting mechanism for providers. • Develop possible strategies are Self-Directed Care Models where funding is attached to and follows the client throughout the continuum of services needed.

17. The Goal • To adopt a process by which the state can approve alternative treatments, non-traditional service models and service innovations that are in addition to benefits under HealthChoices in Pennsylvania. • To develop innovative transitional residential, step down and therapeutic programs to assist with deterring youth from long-term placement and efficiently transitioning into the community. • To develop a continuum of services for all children and youth regardless of insurance status.

18. Key ProductsWhy They Were Useful • The development of “Case Rates” included an analysis of: • Historical practice cost • Best practice cost • Sensitivity and risk of critical assumptions • The goal was to determine predictable monthly cost / rate that would cover the array of services/supports needed for a cohort of high risk children (prevention-treatment-community-based support).