REALIGNING PROGRAMS TO MEET THE NEEDS OF CONSUMERS AND FAMILIES:

1. REALIGNING PROGRAMS TO MEET THE NEEDS OF CONSUMERS AND FAMILIES: FINANCING HOME AND COMMUNITY SERVICES FOR CHILDREN WITH SERIOUS EMOTIONAL DISTURBANCES AND THEIR FAMILIES Sheila A. Pires Human Service Collaborative State Mental Health Olmstead Coordinator’s 3rd Annual Training Institute September 22-24, 2003 Georgetown University Conference Center

2. DEFINITION OF A SYSTEM OF CARE A system of care incorporates a broad array of services and supports that is organized into a coordinated network, integrates care planning and management across multiple levels, is culturally and linguistically competent, and builds meaningful partnerships with families and youth at service delivery, management, and policy levels. Pires, S. 2002. Building systems of care: A primer. Washington, D.C.: Human Service Collaborative

3. SYSTEM OF CARE 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.

4. Values and Principles for the System of Care Core Values 1. The system of care should be child centered and familyfocused, with the needs of the child and family dictating the types and mix of services provided. 2. The system of care should be community based, with the locus of services as well as management and decision-making responsibility resting at the community level. 3. The system of care should be culturally 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.

5. Values and Principles for the System of Care • Children with emotional disturbances should have access to a • comprehensive array of services that address their physical, emotional, • social, and educational needs. • Children with emotional disturbances should receive individualized • services in accordance with the unique needs and potentials of each child • and guided by an individualized service plan. • Children with emotional disturbances should receive services within the • least restrictive, most normative environment that is clinically appropriate. • The families and surrogate families of children with emotional • disturbances should be full participants in all aspects of the planning • and delivery of services. • Children with emotional disturbances should receive services that • are integrated, with linkages between child-serving agencies and programs • and mechanisms for planning, developing, and coordinating services.

6. Values and Principles for the System of Care • Children with emotional disturbances should be provided with • case management or similar mechanisms to ensure that multiple services are • delivered in a coordinated and therapeutic manner and that they can move • through the system of services in accordance with their changing needs. • Early identification and intervention for children with emotional • disturbances should be promoted by the system of care in order to enhance • the likelihood of positive outcomes. • Children with emotional disturbances should be ensured smooth transitions • to the adult services system as they reach maturity. • The rights of children with emotional disturbances should be protected, • and effective advocacy efforts for children and adolescents with emotional • disturbances should be promoted. • Children with emotional disturbances should receive services without regard • to race, religion, national origin, sex, physical disability, or other characteristics • and services should be sensitive and responsive to cultural differences • and special needs.

7. Lack of home and community-based services and supports • Patterns of utilization • Cost • Administrative inefficiencies • Knowledge, skills and attitudes of key stakeholders • Poor outcomes Current Systems Problems Pires, S. (1996). Human Service Collaborative, Washington, D.C.

8. NATIONAL SYSTEM OF CARE ACTIVITY • CASSP – systems of care for children with sed • RWJ MHSPY – systems of care for children with sed • CASEY MHI – systems of care for inner city children • CMHS GRANTS – systems of care for children with serious emotional/behavioral disorders • CSAT GRANTS – systems of care for adolescents with substance abuse problems • ACF GRANTS – systems of care for children involved in the child welfare system • CMS GRANTS – home and community based systems of care for youth in residential treatment • PRESIDENT’S NEW FREEDOM MENTAL HEALTH COMMISSION – home and community based systems of care Pires, S. 2002 Building systems of care: A primer. Washington, D.C.: Human Service Collaborative

9. Control by professionals Partnerships with families Only professional services Partnership between natural and professional supports and services Multiple case managers One service coordinator Multiple service plans for child Single plan for child and family Family blaming Family partnerships Deficits Strengths Mono Cultural Cultural Competence Frontline Practice ShiftsOrrego, M. E. & Lazear, K. J. (1998) EQUIPO: Working as Partners to Strengthen Our Community

10. CONVERGING TRENDS Pires, S. 2003. Building systems of care: A primer. Washington, D.C.: Human Srevice Collaborative

11. Categorical vs. Non-Categorical System Reforms Categorical System Reforms Non-Categorical Reforms Pires, S. (2001). Categorical vs. non-categorical system reforms. Washington, DC: Human Service Collaborative. Pires, S. (2001). Categorical vs. non-categorical system reforms. Washington, DC: Human Service Collaborative.

12. The Total Population of Children and Families Who Depend on Public Systems • Children and families eligible for Medicaid • Children and families eligible for the State Children's Health • Insurance Program (SCHIP) • Poor and uninsured children and families who do not qualify • for Medicaid or SCHIP • Families who are not poor or uninsured but who exhaust their private • insurance, often because they have a child with a serious disorder • Families who are not poor or uninsured and who may not yet • have exhausted their private insurance but who need a particular type • of service not available through their private insurer and only • available from the public sector. Pires, S. (1997). The total population of children and families who depend on public systems. Washington, DC: Human Service Collaborative.

13. Examples of Sources of Behavioral Health Funding for Children and Families in the Public Sector • Medicaid • Medicaid In-Patient • Medicaid Outpatient • Medicaid Rehabilitation Services • Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT) • Mental Health • MH General Revenue • MH Medicaid Match • MH Block Grant • Education • ED General Revenue • ED Medicaid Match • Student Services • Child Welfare • CW General Revenue • CW Medicaid Match • IV-E (Foster Care and Adoption Assistance) • IV-B (Child Welfare Services) • Family Preservation/Family Support • Other • WAGES • Children’s Medical Services/Title V– Maternal and Child Health • Mental Retardation/ Developmental Disabilities • Title XXI-State Children’s Health Insurance Program (SCHIP) • Vocational Rehabilitation • Local Funds • Substance Abuse • SA General Revenue • SA Medicaid Match • SA Block Grant • Juvenile Justice • JJ General Revenue • JJ Medicaid Match • JJ Federal Grants Pires, S. (1995). Examples of sources of behavioral health funding for children & families in the public sector. Washington, DC: Human Service Collaborative.

14. Local OwnershipState Commitment

15. LEVELSTRUCTURE Policy At least 51% vote on governing bodies; As members of teams to write and review RFPs and contracts; As members of system design workgroups and advisory boards Management As part of quality improvement processes; As evaluators of system performance; As trainers in training activities; As advisors to selecting personnel Services As members of team for own children; As family support workers, care managers, peer mentors, system navigators for other families How Systems of Care are Structuring Family Involvement at Various Levels of the System Pires, S. (1996). Human Service Collaborative, Washington, D.C.

16. Types of Services in Systems of Care • Assessment and diagnosis • Outpatient psychotherapy • Medical management • Home-based services • Day treatment/partial hospitalization • Crisis services • Behavioral aide services • Therapeutic foster care • Therapeutic group homes • Residential treatment centers • Crisis residential services • Inpatient hospital services • Case management services • School-based services • Respite services • Wraparound services • Family support/education • Transportation • Mental health consultation • Other, specify Stroul, B.A., Pires, S.A., Armstrong, M.I. (2001). Health care reform tracking project: Tracking state managed care reforms as they affect children and adolescents with behavioral health disorders and their families-2000 State Survey. Tampa: University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health, Department of Child and Family Studies, Division of State and Local Support.

17. Family support and sustenance • Therapeutic services • School-related services • Medical services • Crisis services • Independent living services • Interpersonal and recreational skills development • Vocational services • Additional reinforcers Examples of Services and Supports Provided Through a Wraparound Approach Lourie, I., Katz-Leavy, J. & Stroul, B. (1996). Individualized services in a system of care. In B. Stroul (Ed.), Children’s mental health: Creating systems of care in a changing society: Baltimore, MD: Paul H. Brooks, Publishing Co.

18. EFFICACY OF SERVICES(Barbara Burns’ Research at Duke University) • Most evidence of efficacy: Intensive case management, • in-home services, therapeutic foster care • Weaker evidence (because not much research done): • Crisis services, respite, mentoring, family education • and support • Least evidence (and lots of research): Inpatient, • residential treatment, therapeutic group home

19. SHARED CHARACTERISTICS OF EVIDENCE-BASED INTERVENTIONS • They function as service components within systems of care • They are provided in the community • They utilize natural supports, parents, with training and • supervision provided by those with formal mental health training • They operate under the auspices of all child-serving systems, not • just mental health • They were studied in the field with “real world” children and families • They are less expensive than institutional care (when the full • continuum is in place) Burns, B. and Hoagwood, K. 2002. Community treatment for youth. New York: Oxford University Press

20. “THE CURRENT NEED IS …FOR BUILDING EFFICACIOUS TREATMENT INTERVENTIONS WITHIN EFFECTIVE, COMPASSIONATE, AND COMPETENT SYSTEMS OF CARE” Peter Jensen, M.D. Building Community Treatment for Youth

21. Examples of Sources of Behavioral Health Funding for Children and Families in the Public Sector • Child Welfare • CW General Revenue • CW Medicaid Match • IV-E (Foster Care and Adoption Assistance) • IV-B (Child Welfare Services) • Family Preservation/Family Support • Medicaid • Medicaid In-Patient • Medicaid Outpatient • Medical Rehabilitation Services • Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT) • Other • WAGES • Children’s Medical Services/Title V - Maternal and Child Health • Mental Retardation/Developmental Disabilities • Title XXI - State Children’s Health Insurance Program (SCHIP) • Vocational Rehabilitation • Local Funds • Education • ED General Revenue • ED Medicaid Match • ED Block Grant • Substance Abuse • SA General Revenue • SA Medicaid Match • SA Block Grant • Juvenile Justice • JJ General Revenue • JJ Medicaid Match • JJ Block Grant • Mental Health • MH General Revenue • MH Medicaid Match • MH Block Grant Pires, S. (1995). Examples of sources of behavioral health funding for children & families in the public sector. Washington, D.C. Human Service Collaborative

22. Financing Strategies to Support Improved Outcomes for Children • FIRST PRINCIPLE: • Program Drives Financing • REDEPLOYMENT: • Using the Money We Already Have • The Cost of Doing Nothing • Shifting Funds from Treatment to Prevention • Moving Across Fiscal Years • REFINANCING: • Generating New Money by Increasing Federal Claims • The Commitment to Reinvest Funds for Families and Children • Foster Care and Adoption Assistance (Title IV-E) • Medicaid (Title XIX)

23. Financing Strategies to Support Improved Outcomes • RAISING OTHER REVENUE TO SUPPORT FAMILIES AND • CHILDREN: • Donations • Special Taxes and Taxing Districts for Children • Fees and Third Party Collections Including Child Support • Trust Funds • FINANCING STRUCTURES THAT SUPPORT GOALS: • Seamless Services: Financial claiming invisible to families • Funding Pools: Breaking the lock of agency ownership of funds • Flexible Dollars: Removing the barriers to meeting the unique needs of families • Incentives: Rewarding good practice Friedman, M. (1995). Financing strategies to support improved outcomes for children. Washington, DC: Center for the Study of Social Policy.

24. Where to Look for Money and Other Types of Support Pires, S. (994). Where to look for money and other types of support. Washington, DC: human Service Collaborative.

25. CMHS GRANT SITES FUNDING DIVERSITY

26. CMHS GRANT SITES FUNDING DIVERSITY

27. CMHS GRANT SITES FUNDNG DIVERSITY Koyanagi, C. & Feres-Merchant, D. (2000). For the long haul: Maintaining systems of care beyond the federal investment. Systems of care: Promising practices in children’s mental health, 3. Washington, DC: American Institutes for Research, Center for Effective Collaboration and Practice.

28. What Are the Pooled Funds? Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and Adolescent Services Branch.

29. DAWN Project Indianapolis, IN How Dawn Project is Funded Dawn Project Cost Allocation

30. MA-MHSPY Cambridge-Somerville, MA

31. Risk-Based Contracting Arrangement Pires, S. (1999). El paso county, colorado risk-based contracting arrangement. Washington, DC: Human Service Collaborative.

32. NJ Children’s System of Care InitiativeFOCUS • Children and adolescents with emotional and behavioral disturbances and their families across child-serving systems. • Not a child welfare initiative. • Not a mental health initiative. • Not a Medicaid initiative. • Not a juvenile justice initiative. • An initiative which crosses systems based on the needs of the child & family WWW.NJKIDSOC.ORG

33. NJ Children’s System of Care InitiativeThe Problems • Children and their families often don’t get services they need when and where they need them. • Services are driven by what “door” they enter -- DYFS, Mental Health, Criminal Justice -- rather than • by what is needed. • No single entity is responsible for coordinating care. • Current resources are consumed by expensive • out-of-home services like hospitalization or residential treatment. • There is no common, comprehensive screening and assessment.

34. NJ Children’s System of Care InitiativeThe Fundamental Elements of Reform • Increase funding (rehab option & advocacy) • Provide a broader array of services • Organize and manage services • Provide care that is based on core values • Individualized Service Planning • Family/Professional Partnerships • Culturally Competent Services • Strength-based

35. NJ Children’s System of Care Initiative Other School Referral Family &Self CHILD Child Welfare JJC Court Community Agencies Screening with Uniform Protocols • Contracted • Systems • Administrator CSA • Registration • Screening for self-referrals • Tracking • Assessment of Level of Care Needed • Care Coordination • Authorization of Services • Community • Agencies • Uncomplicated Care • Service Authorized • Service Delivered • CMO • Complex Multi-System • Children • ISP Developed • Full Plan of Care • Authorized FSO Family to Family Support

36. NJ Children’s System of Care InitiativeFinancing Successes • Leveraged $39 million Federal Medicaid reimbursement by pooling state child welfare and children’s mental health funds • Use of the Medicaid Rehab Option and EPSDT • Established “CSOCI CARD” - mechanism to pay FFS for both Medicaid eligible and non-Medicaid eligible children • Established “FAMILY OF ONE” eligibility status

37. NJ Children’s System of Care InitiativeCommunity Development Successes • CMOs have community development funds or seed money • CMOs have flex funds • FSOs develop family support resources • Examples: • Family movement development • After-school tutoring with faith-based partner • After-school recreation activity (Karate) with transportation • Neighborhood family support group for Hispanic families • Youth support organization; peer mentors

38. Finance: the art of passing currency from hand to hand until it finally disappears. Robert W. Sarnoff, son of David Sarnoff and head of NBC

39. To Obtain Copies of Building Systems of Care: A Primer Contact: Mary Moreland, Publications Manager Georgetown University National Technical Assistance Center for Children’s Mental Health 202 687-8803 E-mail: deaconm@georgetown.edu For Further Information About the Primer, Contact: Sheila A. Pires Human Service Collaborative 202 333-1892 E-mail: sapires@aol.com