National Juvenile Justice Network Forum July 28, 2011 4:00 to 5:30 PM

1. National Juvenile Justice Network ForumJuly 28, 20114:00 to 5:30 PM Jim Wotring, Director, National Technical Assistance Center for Children’s Mental Health Teresa King, Training and Technical Assistance Family Resource Specialist, Federation of Families

2. Learning Objectives • Participants will describe 2 core values of a system of care. • Participants will describe 2 primary fund sources used when blending or braiding funding. • Participants will describe 2 benefits of the Affordable Care Act.

3. SYSTEM OF CARE: Definition The system of care model is an organizational philosophy and framework that involves collaboration across agencies, families, and youths for the purpose of improving access and expanding the array of coordinated community-based, culturally and linguistically competent services and supports for children and youth with a serious emotional disturbance and their families.

4. SYSTEM OF CARE: Definition Cont . Systems of care engage families and youth in partnership with public and private organizations to design mental health services and supports that are effective, that build on the strengths of individuals, and that address each person's cultural and linguistic needs. A system of care helps children, youth, and families function better at home, in school, in the community, and throughout life.

5. SYSTEM OF CARE: The Framework Stroul, B., & Friedman, R. (1986). A system of care for children and youth with severe emotional disturbances (Rev. ed.) Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center for Children’s Mental Health. Reprinted by permission.

6. SYSTEM OF CARE CORE VALUES • The mental health component of the system of care should be family – driven, youth-guided, with the needs of the child and family dictating the types and mix of services provided. • The system should be community based, with the focus of services as well as management and decision-making responsibility resting at the community level. • The system should be cultural and linguistically competent, with agencies, programs, and services that are responsive to the cultural, racial, and ethnic differences of the populations they serve. Stroul, B., & Friedman, R. (1986). A system of care for children and youth with severe emotional disturbances (Rev. ed.) Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center for Children’s Mental Health. Reprinted by permission.

7. SYSTEM OF CARE: Guiding Principles • Family Centered (family-driven, youth- guided) will guide system development, evaluation and services delivery at the child and family level • Services will be community-based, culturally and linguistically relevant. • Children/youth and their families have access to comprehensive array of services that address their physical, emotional, social and educational needs. • Children/youth are identified early, provided comprehensive assessment and, if indicated provided needed services.

8. SYSTEM OF CARE: Guiding Principles • Children/youth live in families and are served in the community in which they live • Care coordination ensures that services are delivered in a coordinated manner with linkages between service systems and agencies (planning, developing, and coordinating services) • Full participation of the child/youth and their family ensures “voice” • Transition to adult services is facilitated and actively planned for the individual shall be done no later than their 16th birthday • Rights are protected

9. SYSTEM OF CARE: As a Systems Reform Initiative TO Coordinated service delivery Joint purchasing of services Comprehensive service array Focus on prevention/early intervention Integrated community settingsChildren within families Community-based ownership Creation of “self-help” FROM Fragmented service delivery Categorical programs/funding Limited services Reactive, crisis-oriented Focus on “deep end,” restrictive setting(s) Children out-of-home Centralized authority Creation of “dependency”

10. SYSTEM OF CARE The difference for a family entering a System of Care is that it has been designed to serve multiple needs within a single family. The system of care is for the family who has a child at risk for or already involved with multiple child-serving systems or services, like Juvenile Court, the Department of Child and Family Services, alcohol and other drug counseling, and mental health.

11. SYSTEMOF CARE When a family enters a System of Care, they have heard the phrase “We can help” more times than they can count, and they are frustrated. The children or youth in the family feel that they have never found a “fit” with the services offered to them, or that those services were not enough. The parents or caregivers in the family have been missing work because of the behavioral problems of their child, and they know that bad news is on the other end when someone from their child’s school calls.

12. Goals of the System of Care Initiative • Increased capacity of the systems to work with children, youth and their families; • Increased access of systems to provide effective services for children, youth and their families; • Improved child and family outcomes such as improvements in child wellbeing, increased stability in living arrangements, and increased school attendance;

13. Cuyahoga Tapestry System of Care • Tapestry focuses on strengths – not just in families, but within provider agencies and neighborhood centers as well! • This initiative brings together all the best efforts of the settlement house tradition, community-based care for families, and established mental health, child welfare, and juvenile justice provider agencies with the schools and churches. • It is a “whole life” approach to serving families!

14. Cuyahoga Tapestry System of Care • Tapestry braids formal Medicaid billable mental health services with informal supports. • This lets dollars follow the child, instead of the old way of doing business that meant communities paid for potentially repetitive services. • Tapestry gives families access to an astonishingly thorough network of no-cost or low-cost services.

15. Cuyahoga Tapestry System of Care What does that mean for a family? • Families aren’t forced to travel from agency to agency for the diverse range of services they need • Families stay where they are comfortable, in their home and in their neighborhood • Families connect with a Parent Advocate, who knows the system and their neighborhood • Families stay together!

16. Cuyahoga Tapestry System of Care • Current partners within the system of care have long histories in Cuyahoga County—and saw a need to integrate their efforts to serve the families with the most complicated needs. • Tapestry married clinical expertise with neighborhood know-how • Families benefit because they can receive the best services the county offers within their homes and neighborhoods—no trips downtown to get what they need

17. Cuyahoga Tapestry System of Care Mental Health Court Outcomes • Progress in Therapy/Self Awareness • Medication Compliance • Reduction/Elimination of Psychiatric Hospitalizations • School behavior and Attendance Improve • Academic Performance Improves • Family Functioning/Relationships Improve • Peer Functioning/Relationships Improve • No New Charges • Case Plan Compliance • Development of Informal Supports

18. Cuyahoga County: Example of Redirection, Early Intervention and Braided Funds SOC Funders Group Chaired by Deputy County Administrator for Human Services Family & Children First $$ State Early Intervention Family & System Team $$ & Family Preservation Residential Treatment Center $$$$ Therapeutic Foster Care $$$ “Unruly”/shelter care $ Tapestry $$ System of care grants Strengthening Communities for Youth $$ County ASO: Management Entity Neighborhood Collaboratives & Lead Provider Agency Care Coordination Partnerships Care Coordination Bundled Rate : $1602 per child per mo. - Medicaid Child/family teams Community providers and natural helping networks

19. Test Question 1 What are the 2 Core Values of a System of Care

20. Financing Systems of Care

21. System Planning • Broad participatory planning, create a common vision/mission, develop a logic model? • Develop a communication plan? • Empower action and helping others lead with you? • Identify short term wins (20 case report) • Don’t let up, change takes time • Develop a plan for institutionalizing the behavior

22. Financing Systems of Care • Financing for whom - target population • Financing for what – services • What do the purchasers want to buy? • Juvenile Justice • Child Welfare • Mental Health

23. Where to Look for Money and Other Types of Support Income Generating Activities e.g., Wellness programs Government Federal, State, County, City Business Corporate Giving Programs or Small Business Taxes and Levies State and County Foundations National, Regional, Community, Family Behavioral Health Organizations 3rd Party Reimbursement Individuals Contributions, User Fees, Volunteers Faith-BasedOrgs Service Clubs e.g., Kiwanis, Junior League, Lions Unions Media

24. Sources of Government Funding • Medicaid • Medicaid Inpatient • Medicaid Clinic • Medicaid Rehabilitation Services Option • Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT) • Targeted Case Management • Medicaid Waivers • TEFRA Option • Education • ED General Revenue • ED Medicaid Match • Student Services • Mental Health • MH General Revenue • MH Medicaid Match • MH Block Grant • Other • TANF • Children’s Medical Services/Title V– Maternal and Child Health • Developmental Disabilities • Title XXI-State Children’s Health Insurance Program (SCHIP) • Vocational Rehabilitation • Supplemental Security Income (SSI) • Part C Early Interven. • 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

25. Example of Redirection & Blended Funds CHILD WELFARE Funds thru Case Rate (Budget for Institutional Care for Children w/CHIPS) JUVENILE JUSTICE (Funds budgeted for Residential Treatment for Youth w/Delinquency) MEDICAID CAPITATION ($1557 per month per enrollee) • MENTAL HEALTH • Crisis Billing • Block Grant • HMO Commercial Insurance 11.0M 11.5M 16.0M 8.5M SCHOOLS youth at risk for alternative placements Wraparound Milwaukee County BHO Care Management Organization $47M Families United $440,000 Per Participant Case Rates from CW, JJ and ED range from about $2000 pcpm to $4300 pcpm Provider Network 210 Providers 70 Services Care Coordination Child and Family Team Mobile Response & Stabilization co-funded by schools, child welfare, Medicaid & mental health Plan of Care

26. Test Question 2 Name 2 Fund Sources Used when Blending or Braiding Funds.

27. Finance & the Affordable Care Act- Health Reform

28. What to Expect From the Affordable Care Act • Increased access to mental health and addictions services for the one in four Americans that live with a mental illness. • Expanded public and private insurance coverage for mental health and addiction treatment. • Expanded Medicaid and CHIP programs.

29. HealthInsurance Exchanges

30. Health Insurance Exchanges Eligibility for Participation in Exchanges: Sec. 1312: U.S. citizens and legal immigrants & individuals not incarcerated with incomes up to 400% of the Federal Poverty Level Small businesses After 2017, large employers can participate in Exchanges.

31. Medicaid and CHIP Why Is This Expansion Important For State Behavioral Health Agencies? The expansion of Medicaid to 133% of poverty and increased CHIP coverage to about 6.5 million additional children is estimated to increase enrollment in the programs by 33% by 2019. This expansion will account for the largest reduction in uninsured populations, followed by the Health Exchanges. Large numbers of uninsured individuals, estimated at around 20%, have mental health or substance use problems (Kaiser Family Foundation, 2009).

32. Medicaid and CHIP

33. Medicaid Sec 2402: 1915(i) State Plan amendment. States can amend their State Plans to offer HCBS as State Plan option benefits. Income eligibility is up to 150% of federal poverty level or 300% of the maximum SSI payment (2,200/ month). States can do one plan amendment with several target populations. Cannot waive state-wideness, but can target a specific population (using needs based criteria) Children with SED Children with SED of a particular age Children with 2 or more hospitalizations Source: Bazelon Center: Medicaid Reforms in the Patient Protection and Affordable Care Act

34. Test Question 3 Describe 2 benefits of the Affordable Care Act

35. Jim Wotring, Director National Technical Assistance Center for Children’s Mental Healthjrw59@georgetown.edu202-687-5052Teresa King, Training and Technical Assistance Family and Resource Specialisttking@ffcmh.org202-687-5016