Utilizing Mentoring & Modeling to Improve Services to Youth Through a Medicaid Waiver

1. Utilizing Mentoring & Modeling to Improve Services to Youth Through a Medicaid Waiver Building FASD State Systems May 13-14, 2009 Presenters L. Diane Casto, MPA Barbara Knapp Alaska DHSS, Behavioral Health Alaska DHSS, Behavioral Health Dan Dubovsky, MSW Cheri Scott FASD Center for Excellence Stone Soup Group

2. Alaska’s FASD History • Alaska Native Medical Center with IHS funding began early alcohol-use screening for all pregnant women using Alaska Native Health Services in mid-1980’s. • Established statewide advocacy and services for Alaska Native women and children to reduce and prevention FASD—program eliminated in mid-1990’s. • 1997 Alaska Department of Health & Social Services holds first Alaska FAS Summit. • 1998 Alaska Office of Fetal Alcohol Syndrome established with $300,000 seed-money from AK Mental Health Trust.

3. Alaska’s FASD History • Alaska’s FASD Project—4 primary outcomes: • Prevention of alcohol-exposed births; • Statewide system of community-based FASD Diagnostic Teams—improved diagnostic services; • Quality system of services for individuals with a fetal alcohol spectrum disorder and their families; • Statewide FASD Surveillance System. • October 2000 -- $29 million federal earmark to establish a statewide FASD system of services and program [$5.8 million per year for 5 years]

4. Laying Foundation for FASD Waiver Project • FASD diagnostic data provided clear ‘picture’ of youth with co-occurring SED and FASD diagnoses. • Able to document need for Medicaid Waiver for youth ages 14-21 at high risk for out-of-state placement in RPTC with SED and FASD. • Applied for SED Medicaid Waiver Demonstration Project in 2007 – awarded 1 of 10 Waiver grants. • 5-year award to expend $10 million in existing Medicaid funds on waivered services.

5. An Alaskan Alternative to Residential Psychiatric Treatment • Select the project: • Locate a federal grant Request For Proposal (RFP) • Pick a project no one else has tried • Call a meeting: • Policy makers • Program designers • Computer software designers • Regulations writers • National experts on the subject • Stakeholders

6. An Alaskan Alternative to Residential Psychiatric Treatment • Pick a population to serve: • Youth age 14-20 years old • Meet level of care for Residential Psychiatric Treatment Center, and • With known prenatal exposure to alcohol or a Fetal Alcohol Spectrum Disorder Diagnosis

7. An Alaskan Alternative to Residential Psychiatric Treatment • Make up new acronyms: • TIMS – Treatment Intervention Mentors • 3M – Modeling, Mentoring, Monitoring • RPTC – Residential Psychiatric Treatment Center • Define new services: • Mentor • Training & Consultative Services • Community Transition • Supported Employment

8. An Alaskan Alternative to Residential Psychiatric Treatment • Define Service Providers: Collaborative ventures between two previously unrelated service providers— • Home and Community Based Agencies • Community Mental Health Centers

9. An Alaskan Alternative to Residential Psychiatric Treatment • Home and Community Based Service (HCB) Agencies Traditional Medicaid Waiver Service Providers • Habilitation group home foster home day habilitation • Supported employment services • Hourly & daily respite • Community Transition services

10. An Alaskan Alternative to Residential Psychiatric Treatment • Community Mental Health Centers (CMHC) All HCB Agency services + CMHC services • Individual & Group Skill Development • Case Management • Training & Consultative Services

11. An Alaskan Alternative to Residential Psychiatric Treatment • The Result—A Program Like No Other: Alaska’s 3M Project: Modeling, Mentoring, Monitoring • Unique person centered plan for each youth who still receives Mental Health services and Medicaid health care services - - - • All this and Wraparound Services, too

12. An Alaskan Alternative to Residential Psychiatric Treatment • Pivotal role: Mentor • A person chosen by the family who works under the direction of the Mental Health Agency providing the regular mental health services. • The mentor models positive behaviors and spends quality, one to one time with the youth. • Also, reviews the effectiveness of the services and family supports, can connect family & providers to specialized trainers & consultants to assist family, school & providers of other services.

13. An Alaskan Alternative to Residential Psychiatric Treatment • Stumbling blocks- Agencies • Mental Health Agencies are often unfamiliar with how Medicaid works – fee for service vs. prior authorization for services • HCB Agencies - not getting a large enough share of the service $$$ to make it worth while • Youth in RPTCs – often out of State – have to be released before they stop meeting Level Of Care (LOC) for RPTC. • Easier to find clients close to age 18 • Harder to find younger 14-18 year olds, who could stay with the program longer.

14. An Alaskan Alternative to Residential Psychiatric Treatment • Trouble points - Agencies • Finding mentors – starting out with activity therapists with Mental Health Agency • Finding out-of-home placements – FASD group homes • Community placements – may never have been in RPTC – Getting psychological evaluations done and reports back in a timely manner • Using psychiatric hospital staff • Pioneering telemedicine for Mental Health clinical services

15. An Alaskan Alternative to Residential Psychiatric Treatment • More stumbling blocks – • Unable to identify mentor • Family wants youth in out-of-home placement – but agency has no empty beds • Workforce development issues

16. An Alaskan Alternative to Residential Psychiatric Treatment • 3M Training Original training in 3M Model Started with 2x year large, week long training Agencies can’t release staff that long New training model Moved to on-line training for FASD 101 and Core training “Webinar” follow up training (4 times/year) Bring training to the community providers– train staff, do Level of Care & sign off on plans on same day

17. Why the “3-M” Model? • Individuals with an FASD often learn most by modeling the behavior of those around them • Individuals with an FASD do better having a one-to-one person with them • A mentoring type approach has been shown to be very effective in the prevention of FASD • Mentoring for persons with an FASD is beginning to be tested • Relationships are key to positive outcomes • Monitoring and evaluation are an essential component to ensure continuation

18. What is Mentoring? • A form of teaching that includes walking alongside the person and inviting him or her to learn from your example • Participating in activities with the person rather than connecting the person with activities and then giving the person the responsibility to follow through (as is typical with case management) • Pointing out misinterpretations of words, actions, and body movements when they occur

19. What is Mentoring? • Providing advice, counsel, guidance, and one-to-one encouragement • Helping the person become aware of, and engage in, opportunities • Identifying strengths in the individual and family and building on those strengths

20. What is Mentoring? • Helping improve a person’s feeling about him or herself (self-esteem) • Increasing a person’s competence in various areas • Forming a positive relationship with the person • Respect • Caring • No eject • A therapeutic approach but not a clinical service

21. Mentoring Is Not… • Typical case management • Therapy • Respite • Guardianship • Guarding • A mentor is not a warden

22. What is Modeling? • The activity of recreating the steps of an activity so the person can mimic them • Shaping or molding by demonstrating the best way to do something in a variety of situations • An activity • An emotion • A method of expressing an emotion

23. Modeling Is Not… • Telling someone what to do • “Once and done” • “Do as I say” • “Just do it”

24. What is Monitoring? • Review and evaluation of specific aspects of an activity or program to include • Measuring performance • Assessing adherence to regulations, structure, and terms of the program • Assessing progress • Of the individual and family • Of the program • Of the approach • Providing technical assistance as needed

25. What is Monitoring? • A key to the ability to examine whether a program or approach produces positive outcomes • An ongoing process • Begins with gathering baseline data • Continues with gathering data on an ongoing basis • Data gathered is analyzed for change and trends

26. Monitoring Is Not… • Checking in with a person once in awhile • Vague reports of work being accomplished • A generalized overview of what has occurred • Documenting events long after their occurrence

27. Treatment and Intervention Mentor (TIM) Role • Is: • Mentor • Role model • Coach • Cheerleader • For youth and family • Is not: • Sitter • Disciplinarian • “Spy” for the family • Reward for good behavior

28. Caregiver Perspective – Past experiences with behavioral health system • Few or no support services available until youth in full blown crisis • Services not available in home community • Caregivers had limited understanding of screening, placement decision making process • Limited effective treatment options for youth with FASD once placed in treatment setting • Difficulty getting proper diagnosis

29. Caregiver Perspective – Past experiences with behavioral health system • Few treatment staff understood FASD • Limited contact with youth after placement • Limited training of caregivers to provide needed structure after discharge home • No contact with treatment staff after discharge • Few services available in home community after discharge • Damaged trust

30. Caregiver Perspective – Present Hopes • Triage team works with family, educating about options, process • Increased awareness of impact of FASD on all facets of treatment • Continually expanding interest in staff training and consultation across state • Caregivers at table in BTKH and Waiver planning

31. Caregiver Perspective – Present Hopes • Agencies exploring innovative, alternative approaches to meet needs of youth with FASD • Caregivers and youth able to access training and peer support more easily • Wrap-Around Model

32. Caregiver Perspective – Dreams for the future • Early and accurate diagnosis available statewide • Supports available at first signs of difficulty • Supports always address strengths of the youth and family – family-centered care • Services provided in home community or at least in region – no leaving the state • Services continue into adulthood seamlessly

33. And the Demonstration Continues… • Project has 3 more years of “demonstration project” status • Data collection and evaluation of effectiveness will determine permanent status of the Medicaid Waiver • Alaska only state focusing on youth with co-occurring SED-FASD—project has the potential to establish an “evidence-based” model of intervention for this high-risk population – this project is a great opportunity to establish a new way of serving this population.

34. For More Information Barbara Knapp, Project Director Alaska DHSS, Division of Behavioral Health 3601 C St, Ste 878Anchorage, AK 99503-5935 barbara.knapp@alaska.gov 907-269-3609