Kathy Penkert Kenneth Joe May 15, 2014

1. Lead Agency for the Privatization of Placement Services and Room, Board and Watchful Oversight Resources for Children in Georgia DFCS Foster CarePresentation to Together Georgia membership Kathy Penkert Kenneth Joe May 15, 2014

2. Introduction of Kathy Penkert Child Welfare Lead Agency consultant. Over 15 years experience in the development of Lead Agency models and operations. Worked with 11 Lead Agencies in Florida as well as several Lead Agencies in Texas, Nebraska, Ohio, Philadelphia, Washington RFP responses has resulted in over $380 Million in contracts Knowledge of hands on work flows and procedures for Lead Agency

3. Introduction of Kenneth F. Joe Sr. Child Welfare/Behavioral Health Consultant. 25 years Child Welfare experience: 15 years Private Sector in Illinois, 10 Years Public/Private Sector Georgia Registered Lobbyist Georgia Developed Framework for Performance Based Contracting in Georgia Developed Framework of DFCS Psychotropic Medication Monitoring of Children in Georgia Foster Care Placements Knowledgeable of Lead Agency Models in other States

4. Why are we here? Georgia DCFS has issued a Request for Information (RFI) to gather feedback and input for the development of an RFP to start Privatization Pilots in Regions 3 and 5 for child placement services. Learn more about what form/model the Pilots could take How will that effect providers

5. What to expect today: • Define what DFCS expects from a Lead Agency • Components of a Lead Agency • Child welfare Lead Agency models from other states • Lessons Learnedby Providers that became Lead Agencies • Practice Impact for providers

6. What is a Lead Agency: A Lead Agency is an organization, usually a non-profit child welfare or children’s mental health provider, which contracts with the state to provide or manage some component of direct services to children and their families. The contract is usually risk based and outcomes required. The successful lead agency develops an administrative unit to manage the service delivery.

7. What does a Lead Agency do? Holds the master contract with the state Develops a network of providers and subcontracts and pays for services Implements and assures that services are delivered in such a way to achieve the outcome goals of contract Develops a centralize intake and placement process Participates in case planning and management Gathers data to report to state and also to manage the network and outcomes Provides permanency work with family, independent living including transition, adoption services, etc. Preforms quality and utilization oversight Trains providers Engages community stakeholders

8. Examples of Lead Agencies from other states

9. Texas Child Welfare Single Source Contract Continuum SSCC are Lead Agencies which can both provide services and purchase and manage services Are required to provide out of home placement (foster home and group care), adoption, independent living and eventually work with the family. SSCC have developed a network of paid sub-contracted providers SSCC are at risk with a capitated contract paid on a per diem rate with incentives and penalties

10. Texas Child Welfare Single Source Contract Continuum • SSCC’s have developed Administrative Management Units: • Network Development with subcontractors • Utilization Management to produce outcomes • Quality Assurance and training • Care Coordination • Community relations and stakeholder engagement Payment through per diem rate determined by foster care blended rates, transferred FTE’s, POS funds. SSCC “winner’s” announced with a 6 month start up process.

11. Washington State Managing Entity • Two regions implemented a managing entity model (urban and rural) • ME (like a lead agency) included: • Capitated contract • Network of subcontracted providers • Intake and Placement • Dual Case management with public CM • Involvement of community stakeholders • Involvement of Tribes • State Employees’ Union successfully got a court order to prohibit implementationpost phoning for two years

12. Tennessee Child Service Continuum Lead Agencies provide a continuum of child welfare services with an administrative management entity Texas SSCC has been modeled after Tennessee Dual case management with public CM working with the family Continuum services focuses on out of home placement

13. Nebraska Lead Agency • Currently one “standing” lead agency • System is failing due to flaws in the original model design: • Dual case management (public CM stayed in place) • Lack of control over case decisions • Not fully funded…LA only received money used to buy services, not a global transfer • Payment mechanism…had to use billable hours to draw down funds • Provider agencies were not ready to be a Lead Agency. • Probably will dismantle at some point

14. Florida Lead Agency • Totally privatized system…no public case management. • Currently 18 Lead Agencies which were founded by non-profit child welfare agencies (Devereux, Camelot Community Care, Eckerd Youth Alternatives, etc.) • Provides all child welfare services except child protective investigations: In-home family services and supervision, Out of home placement (foster and group care), Adoption, Independent Living, Visitation, Transportation, etc. • Created early intervention and prevention services • Centralized and decentralized Case Management

15. Florida Lead Agency • Writes reports and represents the child in court. • No reject- no eject system • Funded by a global transfer of funds (Title IV, Chaffee, etc.) • Due to Title IV Waiver lead agencies can use funds flexibly to be able to pay for more community based and family oriented services and innovate. • Utilization Management used to manage the utilization of services, time to permanency and other contract outcomes based on Florida’s CFSR standards

16. Florida Lead Agency Florida DFCS provides overview and monitoring through quality assurance audits Data Driven system…uses the DFCS child welfare SACWIS system to monitor outcomes and as case record Web posted dash boards Competitive procurement process Increased performance and state out comes on CFSR audit (shorter time out of home, increased adoptions, more and faster reunifications) Thinking of applying the Lead Agency to DJJ.

17. What will the Georgia Lead agency do?

18. What will a GA Lead Agency do? The following are the overarching goals of the pilot which will be contracted to the Lead Agency: Build a trauma-informed placement network that provides for optimal, safe and stable placement services to children. Ensure that children’s well-being needs are met. Ensure that children are in the least restrictive and most appropriate placements. Maintain children in their school of origin. Ensure that siblings are placed together. Ensure that family and community connections are maintained. Reduce the use of congregate care placements. Improve youth’s preparation for independent living.

19. What will a GA Lead Agency do? • Intake, referral and placement to services • Single referral point or entry for all services 24/7 in GA • Fast with no long admissions process ( 2 hours in Georgia) • Seamless and hassle free access to all services • Facilitating the best placement that will meet DFCS goal • Immediate placement and transportation • Maintain an up to date placement roster • Ability to respond to crisis situations within 24 hours

20. What will a GA Lead Agency do? • Develop and Subcontract with a Network of Providers • Develop a range of foster homes, group home and other providers that will adopt a “no reject, no eject” policy • Services that will support a capitated/per diem rate payment • Support and help timely permanency, connections to family, community, educational stability and be the least-restrictive environment • Placement of siblings • RFP process or an application or screening process and credentialing requirements • Orientation and training of providers • Contracting or letters of agreement with payment terms

21. What will a GA Lead Agency do? Foster Parent and Staff Approval and Training: • Ensure all sub-contracted CPAs and CCI (including maternity staff) are approved according to all DFCS / RBWO standards. • Ensure all sub-contractor (CPA) foster homes, transferred DFCS foster and developed foster homes remain in full approval status and are approved according to all DFCS / RBWO standards. • Participate in, encourage, and support the implementation and maintenance of foster parent associations. • Working with CPAs and CCI’s in its placement network, assure foster families and direct care workers in its placement network receive additional training as necessary to meet the needs of children who may be or are placed. • Ensure that Partnership Parenting and trauma-informed child welfare training is provided to all network foster parents and staff and that operations are consistent with trauma informed principles.

22. What will a GA Lead Agency do? • Case Planning • Participate in the development of the initial and subsequent family case plans. • Ensure that the placement network CPA or CCI where a child from the pilot regions is placed develops Individual Service Plans that support the DFCS case plan for the child in accordance with RWBO Standards. • Oversight of Children in Foster Care • Ensure that all applicable DFCS and RBWO Minimum Standards regarding the safety , well-being (physical, dental, mental health , educational and behavioral) and permanency services (for example sibling and parent-child visitation) of children are met in each placement network CPA foster home or CCI where DFCS children from the pilot regions are placed.

23. What will a GA Lead Agency do? General Expectations: • Utilization of evidence-based or evidence-informed approaches. • Utilize trauma-informed child welfare principles. • Utilize Partnership Parenting principles. • Ensure that youth receive services that prepare them for transition to independence. • Provide services that are culturally competent, responsive to cultural differences and special needs.

24. What will a GA Lead Agency do? General Expectations (cont.): • Document relevant and meaningful information regarding the Lead Agency’s contacts with children in GA SHINES and GA SCORE, as applicable. • Attend and participate in and ensure that network CPAs and CCIs attend and participate in all necessary meetings, including Family Team Meetings (FTM) with DFCS concerning children placed from the pilot regions. • Ensure providers appear in court when required.

25. What will a GA Lead Agency do? RFI Pages 10-14 defines the role and expectations of the Lead Agency and their Subcontracted CPA/CCI in the following processes: • Child Protective Services • Foster Care and Permanency Services • Placement Match Assessment • Safety: Reporting, Significant Events and CPS • Medical and Dental Services • Education Action Plan • CCFA Referral • Permanency Goal • Support of Case Plan and Case Plan Progress • Contacts with Birth Parents Defines the DFCS Role

26. What will a GA Lead Agency do • RFI Pages 10-14 defines the role and expectations of the Lead Agency and their Subcontracted CPA/CCI in the following processes (Cont.): • Family Team Meetings • Worker/Child Visits • Child Well-being and Parent & Sibling Visits • Legal Proceedings • Independent Living Program • GA SHINES and SCORE Documentation

27. Performance Measures for GA Lead Agency and Payment: RFI Pages 21-24 Identify the Performance Measures expected of the Lead Agency and subcontracted providers. Payment Methodology will be through a “foster care administrative contract” yet to be determined. Possible performance bonus based on outcomes after the first year. DFCS will still pay per diems directly to foster parents or CPA, CCI or Lead Agency if also a provider. Placement cap will be established for Lead Agency also providing services.

28. Implementation process for Lead Agency: • Lead Agency must be ready to initiate service delivery within 75 days of the executed contract. • Written transition plan to include staff roles and responsibilities, the placement referral processes and the Targeted Recruitment Plan for building the placement network. • Pass the DFCS readiness assessment of the Lead Agency. • Transition and accept DFCS supervised foster homes • Be able to perform full operations of the deliverables for Lead Agency or its sub-contracted network.

29. Lessons Learned: What have we learned from the privatization models in other states and what is the impact on provider agencies? And what have we learned about providers who become Lead Agencies?

30. Impact of Lead Agencies on Providers This has affected private agencies by the following: • Providers have become managers and payers by setting up subcontracted networks to provide services • Providers have learned a whole new way of doing business • New services that are more prevention and family oriented have been developed • More community based and less reliant on residential • Increased use of foster and adoptive families • Private agencies have become innovative in creating new services that moves intervention with the family “upstream” and more prevention services

31. Funding/Contracting Mechanisms changed: Contract Market driven and not program (not based on relationships) Competitive Procurement through RFP/ITN: Limited number of contracts Performance expectations Limited number of years and then renewal process Need for Account Management approach to public funders Need for staff to respond to RFP bidding process and contract negotiation process

32. In General…the models have created: Alignment of payment methods or rates with specific results Flexibility and creativity of the private sector Utilization monitored more closely Continuous Quality Improvement to monitor and make adjustments fast Opportunity to Integrate funding streams Fewer provider contracts for state to manage Better outcomes and satisfaction Increased competition driving better outcomes

33. How does a traditional provider become a Lead Agency? Here is where this gets competitive as each organization is going to develop a unique lead agency model based on their review of other states models, research, consultant technical assistance, or just a best guess as to what it will take to get the job done Learn from Impacts on providers in other states DFCS will review the proposed models and chose the two that they think will be developed in such a way that the pilot will be successful

34. Provider Practice Impact: • Move from child individual centered to family centered plan and services • Permanency (shorter time limits for reunification) • Family redefined in new ways: • Father’s more involved • Same sex parents • Grandparents as parents • Group family decision process with the family involved more in case planning

35. Provider Practice Impact: Foster Care has changed: • A more important resource • Evolving to Resource Families (foster to adopt) • Harder kids • Siblings placed together • Visitation with parents and sibs • More expectations for Foster Families: • Training • More complex application process • Role expectations • Work with the bio family • Concurrent planning for reunification and possible permanency

36. Provider Practice Impact: Need for more supports and services to bio-families: • Respite • Shelter/housing • Hard goods • Advocacy • Parent skill building • Safety plan More kids and families cost shifted between systems (juvenile justice, behavioral health, MR/DD)

37. Provider Practice Impacts: • Shorter lengths of out-of home placement • More reliant on step down services (resource families, shelter, independent living) • More use of family placements and services • Leaving children in the bio-family with safety supports • Placing children with relatives with supports • Non-related resource family used less • Increased used of community based services and treatment School based Neighborhood

38. Provider Practice Impacts: Use of tele-communications for services (phone, video, web based, Skype) and consultation with professionals and visitation with parent-child Need for more services and supports for aging out of youth and transitioning youth Need for multi-disciplined approach to case management and service delivery (i.e.: MR/DD combined with Mental Health and/or Substance Abuse) and better assessments for planning More Involvement or cooperation with court systems

39. Provider Practice Impacts: Need to stay ahead of the field and get competitive Information, information, information …early and often Look to the health care, insurance, and pharmacy industries for patterns with fewer provider organizations through mergers, retrenchments, and closing Larger Systems with less “independents”

40. Providers as Lead Agencies Lessons Learned: • LA Providers were not ready for the managed care aspects of the Lead Agency role. They had a hard time shifting to a Lead Agency entity, and did not realize the difference in the new business from the old.....Recognize that virtually every part of your organization will change and should change. • LA Providers did not understand Risk and Risk Management: -Terms of the contract---risk exposure over a length of time. -Covered Populations and covered Services...what was included and what wasn't -Not clinically knowledgeable (MH/SA issues)

41. Providers as Lead Agencies: • LA Providers did not have the Clinical Infrastructure to support Risk Management: • No Utilization Review Process or experience • Intake and assessment process too long • Treatment planning process too lengthy • Treatment goals not consistent with the Lead Agency philosophy • Did not use a wrap around treatment approach, too much focus on the child vs. the family • Not enough in-home orientation in services

42. Providers as Lead Agencies • LA Providers did not understand business practices and generally were not concerned with Profit and Loss. • LA Providers spend too much time in processing and planning by committee. Service staff was not empowered to make treatment planning decisions. • LA Providers did not know how to work with the Juvenile court system and used that as an excuse for a lack of control over the case.

43. Providers as Lead Agencies • LA Providers did not have experience in developing, maintaining and working with a network to deliver services. They lacked: • Contract develop experience • Provider selection process • Payment mechanism • Conflict resolution • LA Providers confused partnership with the concept of subcontracted provider.

44. Providers as Lead Agencies • Providers lacked information and control over their own organization: -Lack the information to manage risk -Couldn't or wouldn't control staff performance -Poor MIS Knowledge and systems • Providers had inadequate MIS systems: -did not understand their own unit costs. -did not have reports or data to support risk taking -could not track clients through a continuum of care

45. Providers as Lead Agencies • LA Providers were too hesitant to capitalize to get the necessary equipment, technical assistance, and staff...spend the necessary money up front. • LA Providers were nonprofit motivated and not competitive enough. Drive capacity through competition and eliminate competition. • Nonprofit board structure held organization back from embracing Lead Agency opportunities

46. Providers as Lead Agencies • LA Providers did not always have enough experience in the competitive market RFP Process or contract negotiation process. • LA Providers were not able to generate staff commitment to the Lead Agency philosophy and lacked staff training. • LA Providers had a difficult time attracting and retaining staff. • The Lead Agency organization did not have experience with gathering outcomes data, and using it as a quality improvement process.

47. Next Steps? • Respond to the RFI • Use a readiness process to determine your agencies strengths and challenges to be a Lead Agency or a subcontracted provider • Determine if you need technical assistance • Determine whether you are going to respond to the RFP as the Lead Agency or partnership. • Inform your Board and get buy-in