Level of Care Tool Utilization

1. Level of Care Tool Utilization A Multi-County Initiative And A Single County Initiative

2. Southwest OhioRegional CollaborativeButler, Clermont, Hamilton, Montgomery, Preble, WarrenSummit County Children Services

3. SORC Background • Sept 2008, Butler Co. Commissioners • Suggested topics: • Regional recruitment of foster/adoptive homes • Private foster care agency reviews • Regional contractual rates • Integrated software pilot • Public/key audience education • Disaster/emergency cooperation

4. SORC: Initial Perceptions….

5. SORC: Identified Opportunities • Given the current and future economic climate we, collectively, realized we could not continue to operate in the same manner • Opportunity to work together to provide the best care to the children and families we serve • Opportunity to better serve children both locally and regionally • Improve placement stability by placing children in the appropriate level of care to meet their need

6. SORC: Level of Care Tool Initiative • Increase agency’s involvement in ensuring children are placed in the least restrictive LOC • Ensure that placement decisions are driven by children’s behavioral characteristics that will impact the demands on the placement resource • Promote similar provider expectations/ requirements across the region • Improve and streamline services to children while reducing administrative burdens on counties and providers

7. SORC: Placement NumbersChildren in Paid Placements • At the end of 2008 there were roughly 2500 children in paid care throughout this six county area • As of March 2010, there were 2409 children in paid care throughout the collaborative area

8. SORC: Placement Dollars • In 2008, the six county region was spending in excess of $60 million dollars for placement costs. • In 2009, the collaborative area spent $60,101,919 for placement costs

9. SORC: LOC Tool Development & Progression • Functional Assessment Scale initially developed by Alice Lin and a research team from UNC/Chapel Hill School of Social Work under a contract with NC Department of Social Services –”N.C. F.A.S.” • Tested for reliability and validity from 1996 through 1997 • In Ohio, the scale went through local modifications in urban counties when being field tested for inter-rater reliability and content validity

10. SORC: SW Tool development & progression • Hamilton County Protocol was developed in 2003 • Butler County Protocol borrowed with permission modified in 2008 • Alice Lin, LOC creator, customized the Southwest Ohio Level of Care Tool in June 2009 • SWLOC Tool assesses for: Basic Foster Care, Therapeutic Low, Therapeutic High, Group Home, Residential Treatment (open and locked)

11. SORC: Conceptual Foundations of the LOC tool • Focus on functioning, not DSM diagnosis, # medications, etc. • Consider strengths and weaknesses of the child’s functioning • Incorporate child welfare domains with behavioral health issues • Used in combination with assessment of family and environmental domains • Preserve rater discretion • Use for admission and continued stay reviews

12. Summit CountyLOC Assessment ToolImplementation

13. Summit’s Background • February 2006, Summit County Children Services implemented The Level of Care Assessment Tool • Summit County developed contracted rates with Providers based on The Level of Care • Prior to 2006 all rates were Provider driven

14. Summit’s Background (cont.) • Prior to the Level of Care and development of the Assessment Tool, there was no true matching • Placements were not based on needs / behaviors

15. Summit’s Initial Thoughts • Children would be placed based on their needs / behaviors • Ensure children would be placed in the Least Restrictive Environment • Children would have only one placement in a custody episode • Reduce paid placement budget • SCCS staff originally afraid it was more work • Some workers felt that they were losing control of their case • Training for Providers, SCCS staff and Juvenile Court staff

16. Summit: Placement Numbers • In January 2006, 318 children in Paid Placement: • 189 Foster Care • 38 Group Home • 91 Residential • In January 2007, 375 children in Paid Placement: • 261 Foster Care • 36 Group Home • 78 Residential • End of 2009, 212 children in Paid Placement: • 123 Foster Care • 40 Group Home • 49 Residential

17. Summit’s Financial Impact • 2005 $15,329,511 • 2006 $13,923,386 • 2007 $13,066,856 • 2008 $11,286,164 • 2009 $10,759,766

18. Summit’s Level of Care Tool • 140 questions with narratives • Tool automatically assigns a Level of Care • Six Levels of Care • Detail, Detail, Detail

19. Summit’s Impact • Reduction in the Paid Placement Budget • Decrease in youth placed in Temporary ER Shelter Care • Decrease number of youth placed in residential care • An On Call 24/7 Placement Manager • Development of Resource Managers & Placement Unit

20. Summit: Goals • Continue to stay within the Paid Placement Budget • Decrease the length of stay for youth in residential care • Ongoing collaboration with Summit County agencies to develop plans for step downs and emancipation plans • Continue to encourage Providers to recruit foster homes in Summit County

21. SORC: Implications & Impact for Providers • Increased standardization, consistency and county participation in decision-making about level of care determination • Having to more clearly define the services being provided • Greater accountability to demonstrate outcomes • The shared challenge of developing service alternatives to fill the gap while being cost effective

22. SORC: Provider Impact (cont.) • Additional opportunities being identified for regional collaboration • Providers fear losing money and in some cases, a reality • Overall reduction in the use of residential care/decreased length of stay duration in residential care settings • Providers fear losing control • Better understanding of agency financial situation and funding streams available

23. SORC: Provider Impact (cont.) • Increased competition for our business • Opportunity for dialogue with counties • Change is hard, for some…..and welcomed by others • “Unfunded Mandates” claimed by some • Some felt the tool was a threat, until the tool was shared with the provider group

24. SORC: Impact on Agency Staff • Staff afraid they were losing discretion • Staff afraid of more work • Differences of opinions if being completed by UM/UR versus Caseworkers • Fear of provider response

25. Bridging communication gap given variety of names for levels of care Distrust in tool validity/reliability Financial impact on providers Meshing small county with large county needs Dealing w/ opposition SORC: Challenges of Implementing

26. SORC: Benefits of implementing • Uniformity from county to county • Open dialogue between counties • Improved dialogue w/ providers • Reduction of costs • Improved confidence of staff in requesting placement type

27. SORC: County to County comparison • All six counties using now • Still some variance from county to county: • Completed by UM/UR or Caseworker • Scored by Supervisor, UM/UR dept, CW, FCFC • Timing of reassessments

28. Ultimately, both SORC and Summit find… Public agencies and private providers share the common goal of providing quality services to youth.