Services and Supports Array Provider Network Natural Helpers Financing

1. Services and Supports Array Provider Network Natural Helpers Financing Sheila A. Pires Human Service Collaborative Lisa Conlan Parent Support Network of Rhode Island Carrie Johnson United American Indian Involvement Michelle Zabel University of Maryland

2. Types of Medicaid Services in Systems of Care Assessment and diagnosis Outpatient psychotherapy Medical management Home-based services Day treatment/partial hospitalization Crisis services – mobile & residential Behavioral aide services Behavioral management skills training Therapeutic foster care Therapeutic group homes Inpatient hospital services Case management services School-based services Respite services Wraparound Family peer support/education Youth peer support Transportation Mental health consultation Early intervention and prevention services Supported independent living Residential treatment centers 2 Stroul, B.A., Pires, S.A., Armstrong, M.I. (2001). Health care reform tracking project: Tracking state managed care reforms as they affect children and adolescents with behavioral health disorders and their families-2000 State Survey. Tampa: University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health, Department of Child and Family Studies, Division of State and Local Support.

3. Example: Broad Service Array - Dawn Services & Supports 3 2005 CHIOCES, Inc., Indianapolis, IN

4. Service Array Focused on a Total Population Family Support Services Youth Development Program/Activities Coordinated Intake Assessment & Treatment Planning Service Coordination Intensive Care Management Clinical Services Universal Targeted Core Services Prevention Early Intervention Intensive Services 4 Pires, S. & Isaacs, M. (1996, May) Service delivery and systems reform. [Training module for Annie E. Casey Foundation Urban Mental Health Initiative Training of Trainers Conference]. Washington, DC: Human Service Collaborative.

5. Evidence-Based Practices Show evidence of effectiveness through carefully controlled scientific studies, including random clinical trials. For example, Multisystemic Therapy, Functional Family Therapy Promising Approaches or Practice-Based Evidence Show evidence of effectiveness through experience of key stakeholders (e.g., families, youth, providers, administrators) and outcomes data. For example, Wraparound, Mobile Response and Stabilization, Family Peer Support Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative. Examples - Source: Burns & Hoagwood. 2002. Community treatment for youth: Evidence-based interventions for severe emotional and behavioral disorders. Oxford University Press and State of New Jersey BH Partnership (www.njkidsoc.org) 5

6. Effectiveness Research(Barbara Burns’ Research at Duke University) Most evidence of efficacy: Intensive case management, in-home services, therapeutic foster care Less evidence (because not much research done): Crisis services, respite, mentoring, family education and support Least evidence (and lots of research): Inpatient, residential treatment, therapeutic group home 6 Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

7. Examples of What You Don’t See Listed as Evidence-Based Practice (though they may be standard practice) • Traditional office-based “talk” therapy • Residential Treatment • Group Homes • Day Treatment • _______________________________________________ • Examples of Potentially Harmful Programs and Effective • Alternatives in Dodge, K., Dishion, T., & Lansford, J. (2006). • “Deviant Peer Influences in Intervention and Public Policy for Youth,” • Social Policy Report, Vol. XX, No. 1, January 2006. • Youth Today: The Newspaper on Youth Work, Vol. 15, No. 7. 7 Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

8. Implications for How RTCs are Utilized Movement away from “placement” orientation and long lengths of stay Residential as part of an integrated continuum, connected to community Shared decision making with families/youth and other providers and agencies Individualized treatment approaches through a child and family team process Trauma-informed care For more information, go to Building Bridges Initiative: 1) www.systemsofcare.samsha.gov 2) Click on Hot Topics 3) Click on Issues in Residential Treatment 8 Data Trends #127, February 2006,University of South Florida.

9. Characteristics of Effective Provider Networks • Responsive to the population that is the focus of the system of care. • Encompass both clinical treatment service providers and natural, • social support resources, such as mentors and respite workers. • Include both traditional and non traditional, indigenous providers. • Include culturally and linguistically diverse providers. • Include families and youth as providers of services and supports. • Are flexible, structured in a way that allows for additions/deletions. • Are accountable, structured to serve the system of care. • Have a commitment to evidence-based and promising practices. • Encompass choice for families and youth. 9 Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

10. The Role of Natural Helpers Emotional support; moral & spiritual guidance System navigation Concrete help & advocacy Decrease social isolation Community navigation Resource acquisition & education Greater understanding of intervention or support strategies Create Time Banks • Natural Helpers are… • Family and friends • Neighbors • Volunteers • Individuals in the community, e.g. mail carrier, minister, storekeeper, etc. • People with similar experiences • Faith-based organizations 10 Lazear, K., (2003) “Primer Hands On”; A skill building curriculum. Washington, D.C.: Human Service Collaborative.

11. Examples of Sources of Funding for Children/ Youth with Behavioral Health Needs in the Public Sector • Education • ED General Revenue • ED Medicaid Match • Student Services • Mental Health • MH General Revenue • MH Medicaid Match • MH Block Grant • Medicaid • Medicaid In-Patient • Medicaid Outpatient • Medicaid Rehabilitation Services Option • Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT) • Targeted Case Management • Medicaid Waivers • TEFRA Option • Other • WAGES • Children’s Medical Services/Title V– Maternal and Child Health • Mental Retardation/ Developmental Disabilities • Title XXI-State Children’s Health Insurance Program (SCHIP) • Vocational Rehabilitation • Supplemental Security Income (SSI) • Local Funds • Child Welfare • CW General Revenue • CW Medicaid Match • IV-E (Foster Care and Adoption Assistance) • IV-B (Child Welfare Services) • Family Preservation/Family Support • Substance Abuse • SA General Revenue • SA Medicaid Match • SA Block Grant • Juvenile Justice • JJ General Revenue • JJ Medicaid Match • JJ Federal Grants 11 Pires, S. (1995). Examples of sources of behavioral health funding for children & families in the public sector. Washington, DC: Human Service Collaborative.

12. Financing Strategies and Structures to Support Improved Outcomes for Children, Youth and Families FIRST PRINCIPLE: System Design Drives Financing 12 Adapted from Friedman, M. (1995). Financing strategies to support improved outcomes for children. Washington, DC: Center for the Study of Social Policy.

13. Redirection Where are you spending resources on high costs and/or poor outcomes? • Residential Treatment? • Group Homes? • Detention? • Hospital admissions/re-admissions? • Too long stays in therapeutic foster care? • Inappropriate psychotropic drug use? • “Cookie-cutter” psychiatric and psychological evaluations? 13

14. Wraparound Milwaukee – Example of Redirection • 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. 14 Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee County Mental Health Division, Child and Adolescent Services Branch

15. Examples of Refinancing Milwaukee County, WI Schools and child welfare contributed $450,000 each to expand mobile response and stabilization services (prevent placement disruptions in child welfare, prevent school expulsions) Is a Medicaid-billable service; contributions from schools and child welfare generate $180,00 to the school contribution and $200,000 to child welfare’s in Federal Medicaid match dollars Cuyahoga County, OH Cross-walked 93 wraparound skill sets to Medicaid billing categories 15

16. Raising New Revenue • Prop 63 in California (1% income tax on millionaires) • Spokane Co., WA – 0.1% sales tax for mental health • Jackson Co., KN – 1.3% per $100 property tax for • mental health • Florida counties – children’s trust funds 16

17. Creating “Win-Win” Scenarios Child Welfare Alternative to out-of-home care high costs/poor outcomes Medicaid Alternative to IP/ER-high cost System of Care Alternative to detention-high cost/poor outcomes Alternative to out-of-school placements – high cost Juvenile Justice Special Education 17 Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

18. The Cost of Doing Nothing If Milwaukee County had done nothing: the $18m. spent by child welfare ten years ago on residential treatment would be $48m. today Project Bloom “Cost of Failure Study” – Early childhood services at an average cost per child of $987/year save $5,693/year in special education 18

19. The Cost of Doing Nothing: Racial & Ethnic Disparities/Disproportionality “…youths of color were less likely to receive outpatient therapy…and more likely to receive residential services.” (Source: McMillen, J., Scott, L.et. al. Use of Mental Health Services Among Older Youths In Foster Care. 2004. Psychiatric Services 55:811-817. American Psychiatric Association) “The study finds greater use of residential treatment centers by black persons and Hispanic persons that is attributable in part to (public sector) managed care” (Source: Snowden, L., Cuellar, E. & Libby, A. Minority Youth in Foster Care: Managed Care and Access to Mental Health Treatment. 2003. Med Care. 41(2): 264-74). University of California Berkley) 19

20. Strategic Financing Analysis • 1) Identify state and local agencies that spend dollars on children’s behavioral health services/supports. • - how much each agency is spending • - types of dollars being spent (e.g., federal, state, local, Tribal, non-governmental) • 2) Identify resources that are untapped or under-utilized (e.g., Medicaid). • 3) Identify utilization patterns and expenditures associated with high costs/poor outcomes, and strategies for re-direction. • 4) Identify disparities and disproportionality in access to services/supports, and strategies to address. • 5) Identify the funding structures that will best support the system design (e.g., blended or braided funding; risk-based financing; purchasing collaboratives). • 6) Identify short and long term financing strategies (e.g., Federal revenue maximization; re-direction from restrictive levels of care; waiver; performance incentives; legislative proposal; taxpayer referendum, etc.). 20 Pires, S. 2006. Human Service Collaborative. Washington, D.C.

21. Where Families, Youth and Family and Youth Organizations Fit Into the Service Array • As direct service providers • Family Liaisons • Care Coordinators • Family Educators • Specific Program Managers (respite, etc) • Youth Peer Mentors • As technical assistance providers & consultants • Training • Evaluation • Research • Support • Outreach/Dissemination 21 Wells, C. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

22. Rhode Island Time Bank Initiative TimeBank Coordinator TimeBank Ambassadors Community Outreach Exchanges Special Projects Database Advisory Board Website Time Bank Core Values: Assets-Redefining Work-Reciprocity-Community-Respect 22 Conlan (2007). Parent Support Network of Rhode Island Infrastructure and Primary Funding Sources.

23. Family Organization Sustainability Strategies Increase public awareness and acceptance of your organization and/or initiative. Develop a fund development plan for sustainability. Learn about all the different potential funding sources that could support your mission and family involvement work. Build relationships and trust with community and state agency partners and other potential funders. Develop a base of knowledge and evaluative results that supports your family involvement efforts in meeting the needs of children, youth, families, community and partners.

24. Example - Family Involvement Center Phoenix, AZ • Contract with State Behavioral Health Agency • Medicaid managed care “administrative functions” contract • Medicaid managed care contract as provider in network • Contract with State child welfare agency Financed initially by foundation grant; now financed by State general revenue (MH), tobacco settlement, federal MH block grant, federal discretionary grant, Medicaid billable services, and child welfare (GR and IV-E waiver)

25. United American Indian Involvement, Inc Service Support Arrays and Financing Seven Generations Child and Family Services Los Angeles Carrie L. Johnson

27. Seven Generations System of Care LA Community Traditional and Spiritual Advisors Natural Helpers UAII DCFS SAIF Clubhouse Seven Generations DMH DMH-Medical Wellness Center SOC Therapists Native Pathways DV/SA Schools Child and Family Suicide Prevention Family Pres Native Pathways CHAT Youth and Parent mentors Health Project Family Support Ah No Ven Probation Central High School Head Start Taniff Other Indian Agencies/Programs

28. Service/Supports and Financing • Developing our Logic Model • Establishing our Services/Supports • What more is needed? • Increase collaborations • Increase Financing- with a focus on Sustainability • Continually reviewing our Cultural Competency plan- Training on Cultural Competency to other service providers and staff, youth and family

29. Service/Support Array, Provider Network, Natural Helpers and Financing 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

30. Continuum of Opportunities, Supports, and Care There is a need for the Children’s Cabinet to agree on a continuum of opportunities, supports, and care, including evidence-based and promising practices, and work toward ensuring that appropriate levels of services and supports are available to every jurisdiction and community to meet their specific population needs, with the intent of improving outcomes and reducing out-of-home placements. Recommendation 1: The Children’s Cabinet is committed to the creation of a full community-based continuum of opportunities, supports, and care that is developed in partnership with local jurisdictions, families and the provider community to meet the specific, individualized needs of children and families. The Children’s Cabinet should prioritize efforts to safely and effectively serve children in their own homes by expanding the continuum of services. These efforts should include increased diversity, quality, and accessibility of in-home services with an emphasis on reunifying children with their families at the earliest possible time. Services should be culturally competent and responsive, and children should receive all supports to which they are entitled.

31. Continuum of Opportunities, Supports, and Care Recommendation 2: The Children’s Cabinet should work collaboratively to serve children who are in an out-of-home placement in their home schools and communities more effectively with fewer placement disruptions resulting in better permanency outcomes for children and families. Recommendation 3: There should be a commitment to diverting youth from detention and commitment within the juvenile justice system. Subject to the availability of funding, consideration should be given to an expansion of the availability and use of delinquency prevention and diversion services with a focus on creating a range of community service and education options while increasing empathy and caring in youth. Recommendation 4: The Children’s Cabinet should continue to make a commitment to utilizing evidence-based and promising practices to ensure that effective community education, opportunities, support, and treatment options are available to the children, youth and families for whom they are appropriate.

32. Youth Peer-to-Peer Support Provided to a youth enrolled in a CME by a youth support partner (YSP) who: Assists in describing the program model Supports the family and/or participant to participate effectively in the Child and Family Team (CFT) meetings and in the POC development and implementation; Works with the Care Coordinator, participant and family to develop the plan of care; and, Assists in accessing services and removing barriers to care. Are individuals with experience with State or local services and systems as a consumer who has had emotional, behavioral or mental health challenges, are 18-26 years old, have completed the required training programs, and are employed by a Family Support Organization.

33. Caregiver Peer-to-Peer Support Provided to the caregiver of a youth enrolled in a CME by a family support partner (FSP) who: Assists in describing the program model Supports the family and/or participant to participate effectively in the Child and Family Team (CFT) meetings and in the POC development and implementation; Works with the Care Coordinator, participant and family to develop the plan of care; and, Assists in accessing services and removing barriers to care. Are legacy family members (individuals who have current or prior experience as a caregiver of a child with Serious Emotional Disturbance (SED) or a young adult with Serious Mental Illness (SMI) who are 21 or older, have completed the required training programs, and are employed by a Family Support Organization

34. EBP Implementation in Maryland: Our Child and Youth Trajectory • 2008, Maryland Child and Family Services Interagency Strategic Plan: Includes evidence-based and promising practices in the theme, “Continuum of Opportunities, Supports and Care:” • Specific Recommendation in the Plan: The Children’s Cabinet should continue to make a commitment to utilizing evidence-based and promising practices to ensure that effective community education, opportunities, support, and treatment options are available to the children, youth and families for whom they are appropriate. • 2008, Children’s Cabinet joins efforts to improve practice and implement EBSs for children, youth and families in Maryland through funding to support implementation, fidelity and outcomes monitoring, and fiscal analysis of EBPs.

35. EBP IMPLEMENTATION CENTER • Obtain data on existing EBPs in Maryland • Conduct a “sizing” of the EBPs to determine which EBPs should be expanded or brought into the state • Provide training on identified EBPs • Identify funding mechanisms to support the ongoing implementation and sustainment of EBPs • Conduct fidelity monitoring on EBP implementation • Evaluate outcomes of EBPs

36. Prioritized EBP’s Trauma Cognitive Behavioral Therapy Functional Family Therapy Multi Systemic Therapy Brief Strategic Family Therapy Multi Dimensional Treatment Foster Care 36

37. Be both strategic and opportunistic Link grant and other funding/policy opportunities together (as they arise) to build upon one another and leverage further systems change: CMHI Grants – MD CARES and Rural CARES Mental Health Transformation and Block Grants PRTF 1915(c) Demonstration Waiver Healthy Transitions Grant (Transition-Aged Youth) National Child Traumatic Stress Network Grants Children’s Bureau Grants to Child Welfare OJJDP Grants to Juvenile Justice State Agency Initiatives Legislative Mandates