Louisiana’s Coordinated System of Care

1. Louisiana’s Coordinated System of Care The Role of the WAA and its Relationship with the Statewide Management Organization in the Coordinated System of Care. Technical Assistance Webinar March 30, 2011

2. Louisiana’s Coordinated System of Care Purpose of today’s webinar is to Acknowledge the national trend and evidence supporting wraparound in systems of care Communicate the Louisiana structure to support wraparound in CSoC implementation Explain the interaction between the WAA and the SMO in Louisiana’s CSoC Answer questions about WAA, the SMO and other issues posed by attendees to support local responses to the RFA

3. Louisiana’s Coordinated System of Care Agenda RFA process and Timeline Overview Presentations by Kathy Sternbach, Mercer Kathy Kliebert, Deputy Secretary, DHH James Hussey, Medicaid Behavioral Health Medical Director, DHH Questions and Answers

4. CSoC Request for Applications Projected Timeline • March 28, 2011- list of regional points of contact posted to www.dcfs.la.gov/csoc • April 1, 2011- updated list of questions and answers posted on www.dcfs.la.gov/csoc • May 13, 2011- 3:30pm- Application deadline • June 3, 2011- Potential presentation by responders • June 16, 2011- Announcement of awards • January 1, 2012- CSoC launch date 4

5. CSoC Request for Applications The response should reflect collaboration and partnership across the region, rather than the efforts of a single “lead agency” or similar entity. This RFA is seeking to understand the level of community support and capacity to work towards CSoC development in the region, rather than looking for an individual agency or entity to manage implementation.

6. CSoC Request for Applications The purpose of this Request for Applications (RFA) is to serve as the first step towards statewide implementation of the CSoC by identifying (1) the regions in Louisiana that are ready to participate in the first phase of CSoC implementation and (2) the communities within those regions that are most prepared to be part of that initial phase The CSoC will implement one Family Support Organization (FSO) and one Wraparound Agency (WAA) per region, and each applying region can only support one FSO and WAA as part of their proposed CSoC under this RFA.

7. TechnicalAssistance for Applicants Webinar Technical Assistance Meetings every Wednesday, 1:00 to 3:00 pm, from 3/23 - 5/4 dialing and webinar log in information will be will be posted on the CSoC website Email Questions and posting of answers on website Questions maybe submitted via email to CSoC.HelpDesk@la.gov through 5/04/2011. Answers to questions will be posted regularly throughout the response period at the CSoC website (www.dcfs.la.gov/csoc).

8. Webinar Schedule 03/23/11 - Stakeholder & Family Leadership in Local CSoCs 03/30/11 – Family Support Organizations 04/06/11 - The Role of the WAA & its Relationship with the Statewide Management Organization in the CSoC 04/13/11 - National Wraparound Initiative (NWI) 04/20/11 - Provider Issues and Related Medicaid Requirements 04/27/11 - FSO and WAA Relationships with the Community 05/04/11 - CSoC Training by the Maryland Innovations Institute

9. Louisiana’s Coordinated System of Care Presentations by Kathy Sternbach, Mercer Kathy Kliebert, Deputy Secretary, DHH James Hussey, Medicaid Behavioral Health Medical Director, DHH

10. Wraparound Facilitation within the CSOC Wraparound Facilitation: Wraparound is an intensive, individualized care planning and management process. It is not a treatment per se. Instead, wraparound facilitation is an intensive care coordination approach that fundamentally changes the way in which individualized care is planned and managed across systems. The wraparound process aims to achieve positive outcomes by providing a structured, creative and individualized team planning process that, compared to traditional treatment planning, results in plans that are more effective and more relevant to the child and family.

11. Wraparound Facilitation within the CSOC Additionally, wraparound plans are more holistic than traditional care plans in that they address the needs of the youth within the context of the broader family unit and are also designed to address a range of life areas. Through the team-based planning and implementation process, wraparound also aims to develop the problem-solving skills, coping skills and self-efficacy of the young people and family members and and integrate the youth into the community by building the family’s social support network.  

12. Wraparound Facilitation within the CSOC The wraparound process centers on intensive care coordination by a child and family team (CFT) coordinated by a wraparound facilitator. The family, the youth, and the family support network comprise the core of the CFT, joined by parent and youth support staff from the FSO, providers involved in the care of the family, representatives of agencies with which the family is involved, and natural supports chosen by the family. The CFT is the primary point of responsibility for coordinating the many services and supports involved, with the family and youth ultimately driving the process.

13. Evidence Base for Wraparound In 2007, 91% of U.S. states had some type of wraparound initiative 62% of the states were implementing some type of statewide initiative. Over 100,000 youth nationally were estimated to be engaged in a well-defined wraparound process The research base has grown substantially: Only three controlled studies in 2003; There are nine such studies as of 2010, plus the first meta-analysis (Suter and Bruns, 2009) Bruns, E.J. and Suter, J.C. (2010). Summary of the wraparound evidence base. In E.J. Bruns and J.S. Walker (Eds.), The resource guide to wraparound. Portland, OR: National Wraparound Initiative

14. Evidence Base for Wraparound Major outcomes include: Fewer restrictive placements, Improved school and broader functioning (CAFAS), Reduced justice system recidivism and detention use, and Reduced mental health symptomatology (CBCL) For more on the evidence-base, visit: http://nwi.pdx.edu/NWI-book/Chapters/Bruns-3.5-(evidence-base).pdf http://depts.washington.edu/wrapeval/presentation.html

15. Coordinated System of Care Model The coordinated systems of care (CSOC) is an evidence-based model that is part of a national movement to develop family driven and youth guided care, keep children at home, in school, and out of the child welfare and juvenile justice system.

16. Coordinated System of Care Model An important CSoC goal is the reduction of highly restrictive out of home placements through the creation and maintenance of coordinated and effective community based services. CSoCs also create partnerships with public and private providers of services that target children, youth and their families in a multi-agency, multi-disciplinary system of services. Both of the above are key roles for the SMO and all Wraparound Agencies in in the CSOC.

17. Proposed System of Care Values and Principles: Family-driven and youth-guided Home and community based Strength-based and individualized Culturally and linguistically competent Integrated across systems Connected to natural helping networks Data-driven, outcomes oriented

18. CSoC is a different approach to service delivery Adoption of a Family-Driven Practice Model Implementation of Wraparound planning, based on National Wraparound Initiative (NWI) Stress and emphasize importance of providing family-driven services in natural settings–homes, schools, and in the community–instead of out or home placements (e.g., residential treatment, psych hospitals, long-term day treatment, etc.)

19. Population of Focus for CSoC & Wraparound Agencies: Detention Secure Care facilities Psychiatric hospitals Residential treatment facilities Development disabilities facilities Louisiana’s CSoC will initially serve children and youth that have significant behavioral health challenges or co-occurring disorders that are in or at imminent risk of out of home placement defined as Addiction facilities Alternative schools Homeless as identified by DOE Foster care

20. Administrative Structure for the CSoC Implement an administrative structure that includes a Multi-Departmental Governance State Purchaser Statewide Management Organization Local Wraparound Agencies Family Support Organizations

21. Statewide Governance Body DHH Office of Behavioral Health Statewide Coordinating Council for the FSO network Statewide Management Organization (SMO) Local Wraparound Agency Local Family Support Organization (FSO) Service Provider Network CSoC structure

22. Current Medicaid Rules Revised to Expand Financing & Service Array Medicaid will work with CMS to amend state plan and establish waivers State Plan Amendments & Waivers – Identify specific population and specific services State Plan Amendments – home and community based services; school based behavioral health services; substance abuse treatment services for children and adults; focus on evidence based and promising practices 1915c Waiver – Establish CSoC for children’s services, wraparound planning, peer supports 1915b Waiver – establish management by statewide management organization (SMO) The SMO will collaborate with CSoC Governance and DHH/OBH to assist in the development of Wraparound Facilitation agencies and Family Service Organizations 22

23. Functions of SMO The contracted Statewide Management Organization (SMO) will serve as the single experienced behavioral health entity, whose role is to provide the following key management functions for the CSoC: Member services (24/7 toll free access) Referral to wraparound agency (WAA) or providers Utilization management Manage and approve services for participants; prior authorize (when needed) Training Quality management functions and reporting Pay claims Provider network management credential, contracts, train, monitor, and ensure compliance from the provider network 23

24. Training to Support Increased Provider Capacity and Expansion of Services All Providers will need to become Medicaid providers Three components are necessary to successfully train providers and build capacity in local communities. Training on these components will be provided as selected communities implement CSoC Wraparound process Building EPB and promising practice capacity Workforce skill development Additionally, the SMO will provide training for WAAs, providers and State staff on operating protocols related to Utilization Management and quality management filing and resolution of grievances and appeals 24

25. Specialized Services for CSoC Target Population: • Wraparound services, including • Assessment • facilitation of the child and family team • individual service plan development • intensive case management • Youth peer support • Psychoeducation - Parent Support and Training • Independent living/skills building • Short term Respite services • Crisis Stabilization 25

26. CSoC will include expansion of state plan to support needed service array Assessment and diagnosis Treatment planning Mental health consultation School-based services Home-based services Outpatient psychotherapy Medical management Day treatment/partial hospitalization Crisis services Behavioral aide services Therapeutic foster care Therapeutic group homes Residential treatment centers Inpatient hospital services Transportation Addictive disorder services 26

27. CSoC and Wraparound are a different approach to service delivery Utilizes a Family-Driven Practice Model Wraparound Facilitation, an intensive, individualized care planning and management process, is not a treatment but an important component in a System of Care for children and families. Wraparound philosophy values the perspectives of the family – including the child or youth – in all phases and activities. Natural supports for the family are increased by building interpersonal relationships and resources available in the family’s network of social and community relationships Activities focus on strengths to help the child and family recognize, utilize, and build talents, assets and positive capacities. 27

28. Role of WAA • WAA’s are providers of administrative services as contracted with the SMO; • WAA Services are funded through savings generated from the effective management of State Plan Services, including inpatient services, residential treatment, and other community-based services. • WAA Performs CSoC Treatment Planning

29. Wraparound Facilitation Through an individualized team planning process, plans are more holistic, effective and more relevant to the child and family than traditional treatment plans. They: address the needs of the youth within the context of the broader family unit in a range of life areas Aim to develop problem-solving, coping skills and self-efficacy of youth and family members Intensive care coordination allows care coordinators to work with youth and families at small ratios. Emphasis on integrating the youth into the community and building the family’s social support network. 29

30. Wraparound Facilitation Wraparound Agencies (WAAs) serve as the locus for access, accountability, service coordination and utilization management functions for populations of children who have or are at high risk for multi-system involvement. WAAs act as a bridge between the Statewide Management Organization (SMO) and families to independently plan and coordinate care. The WAA is responsible for facilitating the wraparound process, convening the child and family teams (CFT), developing individualized plans of care that cross agencies and assigning one accountable care coordinator 30

31. Wraparound Facilitation The SMO refers eligible children/youth to WAA with a 30 day authorization to arrange community services for the child and family while establishing the CFT, with input from the child and family. Inpatient/out-of-home placements must be pre-authorized by the SMO during the initial 30 day and subsequent authorization periods. An assessment by a licensed mental health professional using the CANS must be obtained. The findings are sent to the WAA wraparound facilitator to assist the CFT with the wraparound planning process. The WAA wraparound facilitator submits the care plan to the SMO for review before the end of the 30-day period. 31

32. Wraparound Facilitation WAAs work with youth, families, providers, regional agency staff, the courts, community organizations and FSOs to coordinate plans of care and access to comprehensive services and supports. The WAA ensures participation and integration with child welfare, juvenile justice, and local education and the Family Support Organization (FSO). Additional WAA responsibilities: Track children, services provided and service costs Utilization management/review of each child Quality assurance at the local level Outcomes management/monitoring of individual children Input data into a management information system to track and monitor functions integrated with SMO MIS Monitor and support development of local provider capacity with SMO to fill gaps in service availability 32

33. Wraparound Facilitation The Plan of Care identifies the assigned task and person responsible for implementing the identified support to attain a specific goal. Includes community partners identified by the CFT to provide natural supports for the family to meet the child/youth’s needs. Has a crisis and safety plan section that identifies potential crisis scenarios what action steps or strategies need to be implemented persons responsible to mitigate the risk 33

34. Wraparound Facilitation All WAA staff must participate in training provided by the state prior to the delivery of treatment planning or services under this contract. The state will provide certification for Wraparound Facilitators employed by the WAA, certifying completion of the required training. This certification will be part of the credentialing / subcontracting process administered by the SMO. 34

35. Role of the SMO vs WAACSoC Referral Process – Step 1 Youth, Family, Caregiver, State Agency, Provider Calls SMO toll free line SMO Member Services SMO Care Manager • Takes basic info • Checks Medicaid eligibility • Transfers call (warm line) to SMO Care Manager • Discusses needs • Conducts CANS Brief Screen • If CSoC Eligible, refers to WAA, Independent Assessor and FSO

36. CSoC Referral Process – Step 2 Independent Evaluator FSO CSoC SMO Referrals • Family Education and Family/Peer Support Services • Assistance with CFT process • CANS Assessment • CFT participation Wraparound Agency • 30 Day Authorization for community services • Immediately refers to services during first 30 days • Immediately works with family and youth to assemble Child and Family Team (CFT) • Assists family with Medicaid application, if needed • Initiates the development of a sustainable POC

37. WAA: Developing a Sustainable POC, Step 3 WAA Facilitator Responsibilities • Assembles the CFT identified/ agreed upon by the family/caregiver, child/youth or custodial agency (e.g., natural supports, schools, Certified Family and Cultural Support Specialists, Certified Youth Support and Training Specialists, Judges, staff from DCFS, DOE OJJ, OBH) • Links the Independent Evaluator/CANS information and the FSO to the CFT process and POC • Conducts the Wraparound planning process to identify the individual needs and strengths of the child and family/caregiver • Develops a customized and sustainable wraparound approach and POC, consistent with wraparound planning goals and signed by a licensed behavioral health practitioner • Submits the POC and CFT meeting documentation to SMO care manager for review prior to the end of 30 days from the initial referral

38. SMO: Reviewing and Authorizing A Sustainable POC, Step 4 SMO Care Manager AuthorizationProcess • Care manager reviews the POC for consistency with the child/youth and family/caregiver’s strengths and needs (as identified by CANS, broad assessment and the POC) and utilization guidelines published by the SMO (and approved by CSoC Governance) • If POC meets these criteria, the SMO Care Manager provides authorization of services for a period of up to 90 days for most children/youth, or longer subject to medical and social necessity • If the POC is inconsistent with assessed needs and strengths and the utilization guidelines for the desired services, or it exceed the cost of care limitations (established by CMS Authorities), the SMO Care Manager will make a recommendation for further discussions with the CFT

39. WAA: Referrals and Ongoing Case Management Step 5 Wraparound Facilitator Responsibilities • Assists the CFT to develop a sustainable POC (if initial POC is not authorized by the SMO) through review of the child/youth and family/caregiver’s strengths and needs. Resubmits the POC to the SMO Care Manager for review. The SMO Care Manager will assist the Wraparound Facilitator with clarification of utilization guidelines and cost of care limitations to help the CFT develop an approvable POC • Refers the child/youth and family/caregiver to community resources and providers as soon as the POC is authorized • Provides intensive case management, consistent with the needs of the child/youth and monitors the appropriateness and effectiveness of the POC • Convenes the CFT as needed and to update the POC every 90 days

40. Louisiana’s Coordinated System of Care Questions? CSoC.HelpDesk@la.gov www.dcfs.la.gov/csoc