Greg Lecklitner, Ph.D. Los Angeles County Dept. of Mental Health Child Welfare Division

1. Implementation of Intensive Care Coordination and Intensive Home Based Services in Los Angeles County Greg Lecklitner, Ph.D. Los Angeles County Dept. of Mental Health Child Welfare Division

2. Background • State Katie A. Settlement Agreement • Identification of Class and Subclass • Establishment of a Core Practice Model • Identification of EPSDT Service Entitlements for Subclass Members

3. Settlement Terms • Establishment of a shared management structure between CDSS and CDHCS to develop policy and provide direction consistent with the Core Practice Model • Develop a process to identify Class Members • Facilitate the provision of ICC and IHBS to Subclass Members

4. Settlement Terms • Develop and circulate a manual to instruct Providers on ICC, IHBS, and TFC Services to the extent they are covered by Medi-Cal and describe how they are to be provided consistent with the Core Practice Model • Develop and endorse a training curriculum to support the Core Practice Model • Collect data on service delivery and outcomes, including from ICC, IHBS, and TFC.

5. Katie A. Class Members • Child Welfare Open Case • EPSDT Eligible • Meet Medical Necessity Threshold

6. Katie A. Subclass Members • Meet Class Membership Definition AND receiving or at risk of any of the following • Enrolled in Wraparound • Enrolled in Treatment Foster Care • Receiving Intensive EPSDT Services (e.g. FSP) • Eligible for Special Care Rate • Placed in RCL 10 or Above Group Home • Psychiatric Hospitalization • Seen at MH Urgent Care Center • 3 or More Placements in Past 24 Months due to Behavioral Concerns • Receiving Therapeutic Behavioral Services (TBS)

7. Core Practice Model • Shared Child Welfare/Mental Health Practice Principles • Model of Service for ALL Katie A. Class and Subclass Members • Fundamental Shift in Relationship with Clients and Families and Between Child Welfare and Mental Health • Systems Reform Through Practice Change • Requires Significant Investment in Training and Coaching • Buy in From Leadership

8. Overview of Core Practice Model Concepts • Child and Family Engagement • Family Voice and Choice • Teamwork • Needs/Strengths Based Understanding • Long Term View • Tracking and Adapting • Use of Formal and Informal Supports

9. Intensive Care Coordination • A service that is responsible for facilitating: • Assessment • Care Planning • Service Coordination • Guided by the Strengths and Needs of the Youth and Family • Works across child and family serving systems • Driven by a Child and Family Team (CFT) process • Provided to children currently living in the community as well as to children currently in hospitals, group homes, and other congregate care settings • There must be an identified ICC Coordinator (MH Staff)

10. Development of the Plan • Comprehensive integration of the activities of all parties involved with service to the child/family • Prepared by the ICC Coordinator working with the CFT • Not required to be separate from the Client Plan • May be an extension of the Client Plan • Must include the components of the TCM Plan described in SPA 10-12B • Must be revised periodically

11. EPSDT and the Child and Family Team • Mental Health Providers can claim for their “active participation” in a CFT • Active participation includes “active listening” • Multiple qualified mental health staff may claim for their participation in CFTs • Total claiming time is not limited to the total time of the CFT • T1017HK Procedure Code • Billed at same rate at Targeted Case Management • Must be clearly linked to the treatment plan

12. Intensive Home Based Services • Individualized, strength-based interventions • Designed to ameliorate mental health conditions that interfere with a child’s functioning • Focused on skill building for successful functioning in the community (e.g. social, communication, behavioral, basic living skills) • Delivered consistent with the treatment plan • Engagement of child in community activities • Typically provided by paraprofessionals • Available wherever and whenever needed

13. EPSDT and IHBS • Claimed using H2015HK procedure code • Reimbursed at same rate as Mental Health Services • Coordinated with other SMHS • Identified in the client’s treatment plan • Service lockouts • Day Treatment Rehab or Day Treatment Intensive • Group Therapy • Therapeutic Behavioral Services • Targeted Case Management

14. Pathway to ICC and IHBS

15. Keys to Implementation Success • Support of leadership • Collaborative management structures • Ability to share information • Braiding of funding resources • Strong training and coaching resources • Performance targets • Quality Improvement process

16. Barriers to Implementation • Competing priorities • Resistance to change (institutional and individual) • Child welfare and mental health cultural differences • Financial • Staying the course

17. Joint Management Structure • Cooperative Arrangement Between Stakeholders • State and County Levels • Data and Information Sharing • Training and Technical Assistance • Policies and Procedures • Monitoring and Quality Assurance • Resources • Ongoing Commitment and Support

18. Katie A. Joint Management Structure • Katie A. Executive Leadership Team • DCFS/DMH/CEO • Katie A. Project Leadership Team • Advisory Panel/Attorneys/DCFS/DMH/CEO • Katie A. Implementation Teams • DCFS/DMH/CEO • Budget • Training • Wraparound • Coordinated Service Action Teams • Consent and Release of Information • Data • Agreement Regarding Policy Development

19. Joint Financial Commitment • DMH/DCFS Memorandum of Understanding • Infrastructure • Braiding of Funding • Wraparound • Case Rate • EPSDT • MAT • MAT DCFS • MAT DMH

20. Timeline: County’s Settlement Progress

21. The Los Angeles County Children’s MH System 78 Contracted Children’s Mental Health Providers Over 9400 Rendering Providers Spread across over 4,000 square miles $575M in Children’s MH Contracts $120M in Katie A. Targeted Contracts (Wrap/MAT/TFC) Serve over100K Individuals up to Age 21 Per Year FY 11-12 Served over 25K Children/Youth with Open DCFS Cases at a cost of over $240M Current Service Capacity Over 2600 children enrolled in Wraparound Almost 1,200 MHSA FSP TAY slots 1,700 MHSA FSP Children’s slots 300 contracted TFC beds Almost 5,000 MAT assessments conducted annually

22. Identification of Class Members in Los Angeles County • Development of Mental Health Screening Tools • Implementation of Coordinated Services Action Teams • Coordinate Mental Health Referrals • Establish Mental Health Benefits • Obtain Consent and Release of Information • Co-location of Mental Health Staff • Triaging of Service Referrals Based on Acuity of Need

23. Child Welfare/Mental Health Information Sharing • Weekly Matching of Child Welfare and Mental Health Client Data Systems • Identification of Mutual Clients • Development of Reports • Weekly Mental Health Alerts to Child Welfare Social Workers and Supervisors • Protocol for Immediate Updates on Urgent Referrals

24. Screening Results • Over 9,000 children screened this fiscal year • 85% Positive Mental Health Screens • <1% Acute • 1% Urgent • 98% Routine • Avg. No. of Days Between Case Opening and Screening – 3 • Avg. No. of Days Between Screening and Referral – 5 • Avg. No. of Days Between Referral and MHS Activity - 1

25. Katie A Class Subclass Class only

26. Los Angeles County DataFY 2011-2012

27. Service Costs

28. Subclass Flags

29. Multiple Flags • One or Two Flags 77% • Three or Four Flags 17% • Five or Six Flags 5% • Seven or More Flags 1%

30. Service Cost by Age Group

31. Service Cost by Service Location

32. Service Type Distribution

33. Los Angeles County Implementation of ICC and IHBS • Participation in Katie A. State Negotiation and Implementation Workgroups • Alignment with key Los Angeles Katie A. commitments • Core Practice Model • Wraparound expansion • Quality Service Review • Members of ICC and IHBS Manual Workgroup • Members of Core Practice Model Guide Workgroup • Establishment of Stakeholder Implementation Planning Team • Support of Katie A. Advisory Panel

34. ICC/IHBS Pilot Project • Funded with MHSA FCCS Prudent Reserve Dollars • SEI process to identify providers • Statement of work • Adherence to Core Practice Model • Provision of ICC and IHBS • Linked to key system touch points • DCFS Command Post • Psychiatric Hospital discharges • Urgent Care Center • Oversight committee

35. Training • CDHCS/CDSS Regional Training • Los Angeles County Training • ICC/IHBS Manual • Core Practice Model Guide • Technical Assistance • Identification of “Best Practice” providers

36. Staged Implementation • Initial implementation through Wraparound and Residentially Based Services programs • Treatment Foster Care • Full Service Partnerships • Children with Special Care Rate • Children in Group Homes • Etc.

37. Service Delivery Tracking • Shared database • Monthly reports • Provider alerts • Administrative reviews • Ongoing Quality Service Reviews

38. Quality Services Review What is QSR • Quality Service Review (QSR) is an ORGANIZATIONAL LEARNING PROCESS offering ways of knowing what’s working and not working in practice for which children and families and why. • QSR tests the PRACTICE MODEL used in actual cases. • QSR connects results to local FRONTLINE CONDITIONS. • QSR supports TEACHING & LEARNING PROCESSES that clarify expectations, provide useful feedback, affirm good work. • QSR stimulates NEXT STEP ACTIONS taken to improve practice and results at all levels of the organization.

39. How Does QSR Work? • Uses in-depth CASE REVIEWS to measure key system functions such as participation, teamwork and coordination, assessment, service planning and implementation • Uses CASE STORIES to reveal what is happening and working for families. • Uses QUALITATIVE INDICATORS to describe the quality and consistency of local practice. • Uses local FOCUS GROUP / KEY STAKEHOLDER INTERVIEWS along with case stories, data patterns, and local working conditions to find and affirm what’s working now and to surface areas where even better results might be achieved in the future.

40. SAFE - Shifting from Blaming to Learning Blame the Person Improve the System • INDIVIDUAL: • - Find-out who screwed-up, “ding’em,” require “Corrective Action!” • PERSON FOCUS: • - Who did it? • - What you did was wrong! • PUNISHMENT: • - It’s your fault! [GOT YA!] • COVER-UP FEAR = NO LEARNING: • - I won’t reveal my mistakes. • - It’s not worth it to take risks. • SYSTEM: • - Find things in our system that affect positive outcomes & good practice. • PROBLEM FOCUS: • - What happened here? • PERFORMANCE: • - Let’s see what we can do to get the results we want. • OPENNESS & SAFE LEARNING: • - We want to learn more about this problem so that we can do better in the near future.

41. Safety Stability Pattern Permanency Prospects Living Arrangement Health/Physical Well-being Emotional Well-being Learning & Development Family Functioning & Resourcefulness Caregiver Functioning Family Connections Engagement Voice and Choice Teamwork Assessment & Understanding Long-term View Planning Supports & Services Intervention Adequacy Tracking & Adjustment PRACTICE INDICATORS STATUS INDICATORS

42. What We Have Learned So Far About Practice Needs(Based on the Reviews Conducted) • Improved Engagement– engaging families and giving voice and choice to children, parents and caregivers in making decisions - enhances the quality and durability of working relationships and participation of the family in their case plans, leading to better outcomes. • Better Assessment– strength-based identification of needs helps gain understanding of underlying needs required for true and lasting change to occur. • Improved Long Term View–provides a clearly articulated vision and guide all the work toward safe case closure. • Better Teamwork–improves function of the total support system around the family: to unite, communicate, and coordinate actions toward the case plan goals and following case closure.