BUILDING SYSTEMS OF CARE: CRITICAL STRUCTURES AND PROCESSES

1. BUILDING SYSTEMS OF CARE: CRITICAL STRUCTURES AND PROCESSES Presentation by: Sheila A. Pires Human Service Collaborative November 3, 2005 Sponsored by the Pennsylvania Child Welfare Training Program

2. Purpose and Structure of the Training • Increase knowledge about what is involved in building • systems of care: critical structures, essential process • elements, examples – Didactic, Questions/Discussion • Assess system-building progress and stage of • development – Break out by County/Facilitated Discussion • Develop specific action agendas to advance • system-building efforts – Break out by County/Facilitated • Discussion/Technical Assistance • Peer Learning – Reporting Back/Large Group Discussion

3. Definition of a System of Care A system of care incorporates a broad array of services and supports for a defined population 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.

4. National System of Care Activity • CASSP • RWJ MHSPY • CASEY MHI • CMHS GRANTS • CSAT GRANTS • ACF GRANTS • CMS GRANTS • PRESIDENT’S NEW FREEDOM MENTAL HEALTH COMMISSION • STATE INFRASTRUCTURE GRANTS Pires, S. (2002) Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

5. System of care is, first and foremost, a set of values and principles that provides an organizing framework for systems change on behalf of children, youth and families. Pires, S. 2005. Human Service Collaborative. Washington, D.C.

6. Values and Principles for the System of Care • CORE VALUES • Child centered and family focused • Community based • Culturally competent 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. Values and Principles for the System of Care • Comprehensive array of services/supports • Individualized services guided by an individualized service plan • Least restrictive environment that is clinically appropriate • Families and surrogate families and youth full participants in all aspects of the planning and delivery of services • Integrated services Continued … 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.

8. Values and Principlesfor the System of Care • Care management or similar mechanisms • Early identification and intervention • Smooth transitions • Rights protected, and effective advocacy efforts promoted • 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 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.

9. Principles of Family Support Practice • Staff & families work together in relationships based on equality and respect. • Staff enhances families’ capacity to support the growth and development of all family members. • Families are resources to their own members, other families, programs, and communities. • Programs affirm and strengthen families’ cultural, racial, and linguistic identities. • Programs are embedded in their communities and contribute to the community building. • Programs advocate with families for services and systems that are fair, responsive, and accountable to the families served. • Practitioners work with families to mobilize formal and informal resources to support family development. • Programs are flexible & responsive to emerging family & community issues. • Principles of family support are modeled in all program activities. Family Support America. (2001). Principles of Family Support Practice in Guidelines for Family Support Practice (2nd ed.). Chicago, IL.

10. Adolescent Centered Community Based Comprehensive Collaborative Egalitarian Empowering Inclusive Visible, Accessible, and Engaging Flexible Culturally Sensitive Family Focused Affirming Youth Development Principles Pires, S. & Silber, J. (1991). On their own: Runaway and homeless youth and the programs that serve them. Washington, D.C.: Georgetown University Child Development Center.

11. System of Care: Operational Characteristics • Collaboration across agencies • Partnership with families • Cultural & linguistic competence • Blended, braided, or coordinated financing • Shared governance across systems & with families • Shared outcomes across systems • Organized pathway to services & supports • Interagency/family services planning teams • Interagency/family services monitoring teams • Single plan of care • One accountable care manager Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

12. System of Care: Operational Characteristics • Cross-agency care coordination • Individualized services and supports “wrapped around” • child/family • Home- & community-based alternatives • Broad, flexible array of services and supports • Integration of clinical treatment services & natural • supports, linkage to community resources • Integration of evidence-based and effective practices • Cross-agency MIS Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative

13. Current Systems Problems • Lack of home and community-based services and supports • Patterns of utilization • Cost • Administrative inefficiencies • Knowledge, skills and attitudes of key stakeholders • Poor outcomes • Financing structures • Pathology-based/medical models, deficit-oriented, punitive systems Pires, S. (1996). Human Service Collaborative, Washington, D.C.

14. Characteristics of Systems of Care as Systems Reform Initiatives FROM Fragmented service delivery Categorical programs/funding Limited services Reactive, crisis-oriented Focus on “deep end,” restrictive Children out-of-home Centralized authority Creation of “dependency” TO Coordinated service delivery Blended resources Comprehensive service array Focus on prevention/early intervention Least restrictive settings Children within families Community-based ownership Creation of “self-help” Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

15. SYSTEMS CHANGE FOCUSES ON: • Policy Level (e.g., financing; regs; rates) • Management Level (e.g., data; QI; HRD; system • organization) • Frontline Practice Level (e.g., assessment; care planning; • care management; services/supports provision) • Community Level (e.g., partnership with families, youth, • natural helpers; community buy-in) Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

16. Frontline Practice Shifts 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 Orrego, M. E. & Lazear, K. J. (1998) EQUIPO: Working as Partners to Strengthen Our Community

17. Examples of Family Members: Shifts in Roles and Expectations Lazear, K. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

18. 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.

19. 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. Human Service Collaborative: Washington, D.C.

20. Systems of Care More complex needs IntensiveServices Accessiblehigh-quality services and supports 2 - 5% Assessment, Prevention and Universal Health Promotion 15% 80% Less complex needs

21. Child Welfare Population Issues • All children and families involved in child welfare? • If subsets, who? • Demographic: e.g., infants, transition-age youth • Intensity of System Involvement: e.g., out of home placement, • multi-system, length of stay • At risk: e.g., • Children with natural families at risk of out of home placement? • Children in permanent placements that are at risk of disruption ? • (e.g., subsidized adoption, kinship care, permanent foster care) • Level of severity: e.g., • Children with serious emotional/behavioral disorders, serious • physical health problems, developmental disabilities, • co-occurring Pires, S.A. 2004. Human Service Collaborative. Washington, D.C.

22. Example: Transition-Age Youth What outcomes do we want to see for this population? • Policy Level: • What systems need to be involved? • e.g., Housing, Vocational Rehabilitation, Employment • Services, Mental Health and Substance Abuse, Medicaid, • Community Colleges/Universities, Physical Health, Juvenile • Justice, in addition to Child Welfare • What dollars/resources do they control? Continued

23. Example: Transition-Age Youth • Management Level: • How do we create a locus of system management • accountability for this population? • E.g., In-house? Lead community agency? • Frontline Practice Level: • Are there evidence-based/promising approaches targeted • to this population? • What training do we need to provide and for whom to • create desired attitudes, knowledge, skills about this • population? • What providers know this population best in our • community? Continued

24. Example: Transition-Age Youth • Community Level: • What are the partnerships we need to build with • youth and families? • How can natural helpers in the community play a role? • How do we create larger community buy-in? • What can we put in place to provide opportunities • for youth to contribute and feel a part of the larger • community? What does our system design look like for this population?

25. Child Welfare Outcomes • Safety • Permanency • Well-Being Difficult to achieve without taking a system of care approach

26. Examples of Sources of Funding for Children/Youth with Behavioral Health Needs in the Public Sector • Education • ED General Revenue • ED Medicaid Match • Student Services • Mental Health • MH General Revenue • MH Medicaid Match • MH Block Grant • Medicaid • Medicaid In-Patient • Medicaid Outpatient • Medicaid Rehabilitation Services Option • Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT) • Targeted Case Management • Medicaid Waivers • Katie Beckett Option • 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 • Supplemental Security Income (SSI) • Local Funds • 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 Pires, S. (1995). Examples of sources of behavioral health funding for children & families in the public sector. Washington, DC: Human Service Collaborative. Revised 2005.

27. WHO CONTROLS POLICY AND DOLLARS? • Key • State Medicaid Agencies • State/Local Child Welfare Agencies • State/Local Mental Health Authorities • Public Health and Primary Care • State/Local Education Agencies • State and Local Juvenile Justice Systems • Some Others • Commercial Insurers • Employment Services • State/Local Substance • Abuse Agencies • Housing Pires, S. (2004). Human Service Collaborative, Washington, D.C.

28. OTHER CRITICAL PLAYERS • “Gatekeepers” (e.g., managed care organizations, judges, interagency teams) • Providers • Natural Helpers and Community Resources • Families • Youth Pires, S. (2004). Human Service Collaborative, Washington, D.C.

29. Local OwnershipState Commitment Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative

30. Converging Trends Pires, S. (2003). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

31. Efficacy of Research(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 Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

32. Evidence-Based Practices And Promising Approaches Evidence-based practices Show evidence of effectiveness through carefully controlled scientific studies, including random clinical trials Promising approaches Show evidence of effectiveness through experience of key stakeholders (e.g., families, youth, providers, administrators) and by data collected by program/system Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

33. Examples of Evidence-Based Practices • Multisystemic Therapy (MST) • Multidimensional Treatment Foster Care (MDTFC) • Functional Family Therapy (FFT) • Cognitive Behavioral Therapy (various models) • Intensive Care Management (various models) Examples of Promising Practices • Family Support and Education • Wraparound Service Approaches • Mobile Response and Stabilization Services Source: Burns & Hoagwood. 2002. Community treatment for youth: Evidence- based interventions for severe emotional and behavioral disorders. Oxford University Press and State of New Jersey BH Partnership (www.njkidsoc.org)

34. Examples from Hawaii’s List of Evidence Based Practices HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd

35. Examples from Hawaii’s List of Evidence Based Practices HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd

36. Examples from Hawaii’s List of Evidence Based Practices HA Dept. of Health, Child & Adolescent Division (2005). Available from: http://www.hawaii.gov/health/mentalhealth/camhd

37. KAUFFMAN BEST PRACTICES PROJECT AND NATIONAL CHILD TRAUMATIC STRESS NETWORK • Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) • Abuse Focused-Cognitive Behavioral Therapy (AF-CBT) • Parent Child Interaction Therapy (PCIT)

38. Shared Characteristics of Evidence-Based (and Promising)Interventions • Function as service components within systems of care • Provided in the community • Utilize natural supports, parents, with training and supervision provided by those with formal mental health training • Operate under the auspices of all child-serving systems, not just mental health • Studied in the field with “real world” children and families • 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.

39. “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 Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

40. EXAMPLES OF SYSTEMS OF CARE

41. Mental Health • Crisis Billing • Block Grant • HMO Commercial • Insurance Child Welfare Funds thru Case Rate (Budget for Institutional Care for CHIPS Children) Juvenile Justice (Funds Budgeted for Residential Treatment for Delinquent Youth) Medicaid Capitation (1557 per Month per Enrollee 9.5M 8.5M 10M 2.0M Wraparound Milwaukee Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee County Mental Health Division, Child and Adolescent Services Branch Management Entity: Wraparound Milwaukee Management Service Organization (MSO) $30M Per Participant Case Rate Provider Network 240 Providers 85 Services Care Coordination Child and Family Teams Plans of Care Mngt. Entity: County Agency

42. OUTCOMES (Milwaukee Wraparound) • 60% reduction in recidivism rates for delinquent • youth from one year prior to enrollment to one year • post enrollment • Decrease in average daily RTC population from 375 • to 50 • Reduction in psychiatric inpatient days from 5,000 days • to less than 200 days per year • Average monthly cost of $4,200 (compared to $7,200 • for RTC, $6,000 for juvenile detention, $18,000 for • psychiatric hospitalization

43. Next Phase of Milwaukee Wraparound • Partnership with HMO to become “medical/clinical” • home for all children in foster care in the county – • Locus of accountability for managing physical, • dental, and behavioral health care to achieve ASFA • well-being outcomes

44. DAWN Project Indianapolis, IN How Dawn Project is Funded Dawn Project Cost Allocation Management Entity: Non profit behavioral health organization

45. Service coordination plans, including safety and crisis plan Broad array of treatment and supportive services Extensive provider network, paid fee for service More Dawn Features

46. Dawn Service Array

47. Dawn Service Array, Continued

48. 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

49. El Paso County, Colorado State-Capped Out of Home Placement Allocation County DHS acts as MCO (contracting, monitoring, utilization review) BH Tx $$ matched by Medicaid. Capitation contract with BHO with risk-adjusted rates for child welfare-involved children Child Welfare $$ Case rate contract with CPA Joint treatment planning approved by DHS Child Placement Agencies (CPA) Responsible for full range of Child Welfare Services & ASFA (Adoption and Safe Families ACT) related outcomes Mental Health Assessment and Service Agency (BHO) Responsible (at risk) for full range of MH treatment services & clinical outcomes & ASO functions Pires, S. (1999). El paso county, colorado risk-based contracting arrangement. Washington, DC: Human Service Collaborative.

50. Types of Outcomes Achieved by Systems Of Care • Reduction in inpatient hospitalization and residential • treatment placements and lengths of stay • Reductions in detention rates • Reductions in out-of-home placements and lengths of • stay • Improved clinical and functional outcomes • Higher family and youth satisfaction • Lower costs per child served for total system if • a range of home and community-based is in place