A Waiver for Children with a Serious Emotional Disturbance (SEDW)

1. A Waiver for Children with a Serious Emotional Disturbance(SEDW) A collaborative effort to achieve better outcomes for children with serious emotional disturbance September 9, 2009

2. Welcome & Introductions

3. Presenters • Connie Conklin, MDCH • Joan Deschamps, MDCH • Debbie Milhouse-Slaine, MDCH • Andy Thalhammer, MDHS

4. Today’s Presentation • Overview the SEDW • Eligibility requirements • Services • Currently participating sites • Wraparound • Funding

5. History of 1915 (c) Waivers • Legislation • Enacted under the Reagan administration • Title XIX of the Social Security Act • Michigan DCH’s (c) and (b)(c) Waivers • Waiver for children with a serious emotional disturbance • Children’s Waiver Program • Habilitation Supports Waiver

6. SEDW • The SEDW is a 1915 (c) waiver that: • Is separate from the Mental Health 1915 (b) (c) Medicaid managed care waiver for specialty mental health services and supports, using a capitation payment system • Is billed “fee for service”, and • Provides enhancements or additions to Medicaid State Plan mental health coverage

7. SEDW • Currently approved through Sept. 2013 • Administered by the DCH and managed by CMHSPs • Provide in-home services and supports to children with serious emotional disturbance and their families • Available in enrolled counties only

8. Purpose of 1915 (c) Waiver • Provide Medicaid coverage to children who: • Without the provisions of this waiver would require hospitalization or institutionalization • Would otherwise not be Medicaid eligible while residing with their birth or adoptive families

9. Purpose • The waiver provides: • Services that are enhancements or additions to Medicaid State Plan coverage • Federal match funds to support collaborative service delivery in a child’s community

10. SEDW Eligibility Criteria • The child must: • Be under the age of 18, • Reside with his/her birth/adoptive parents(s), a relative who is the child’s legal guardian, or in foster care with a permanency plan. • Have a primary DSM Axis I mental health diagnosis, • Be in need of and receive at least one Waiver service per month • MeetCMHSP contract criteria for and is at risk of inpatient hospitalization in the state psychiatric hospital

11. Inpatient Admission Criteria: Children Through Age 21 “Inpatient psychiatric care may be used to treat a child or adolescent with mental illness or serious emotional disturbance who requires care in a 24-hour medically structured and supervised facility. The SI/IS criteria for admission are based on the assumption that the beneficiary is displaying signs and symptoms of a serious psychiatric disorder, demonstrating functional impairments and manifesting a level of clinical instability (risk) that are, either individually or collectively, of such severity that treatment in an alternative setting would be unsafe or ineffective.”

12. Eligibility Criteria…continued • The child must have at least one of the following: • Severe psychiatric signs and symptoms • Disruptions of self-care and independent functioning • Harm to self or others • Drug/Medication complications or co-existing general mental condition requiring care • Special consideration: If Substance Abuse Psychiatric condition must be primary

13. Eligible Criteria … continued • The Child must demonstrate serious functional limitations that impair his/her ability to function in the community (functional criteria is identified using the Child and Adolescent Functional Assessment Scale [CAFAS]) • CAFAS score of 90 or greater for children age 12 or younger; or • CAFAS score of 120 or greater for children age 13 to 18.

14. Financial Eligibility • The Child must meet Medicaid eligibility criteria • Note: If a child is not Medicaid eligible while residing with his/her family and determined clinically eligible for the SEDW, the child can be viewed as a “family of one” to meet financial eligibility for Medicaid.

15. Covered Waiver Services • Wraparound Services • Community Living Supports • Family Training • Family Training & Support (family support partners) • Respite Care • Therapeutic Activities (art, music, rec) • Therapeutic Child Foster Care • Therapeutic Overnight Camp • Transitional Services

16. OtherCovered Services • Mental Health State Plan services that can be billed to Medicaid on a fee for service basis by the CMHSPs • Natural supports • In-kind services provided by community agencies

17. Skill development activities of daily living Skills, such as: Personal hygiene Household chores School attendance Staff assistance, support and/or training with: socialization skills, interactions, and internal controls Community Living Services (CLS)

18. Family Home Care Training • Training and counseling services provided by professional staff for the families of individuals served on the waiver. • Instruction about treatment interventions and support intervention • Counseling service for family members

19. Family Support & Training (FS&T) • FS&T, provided by a parent support partner, which supports parents/families of children with SED to: • Be empowered, • Be confident, and • Have skills that will enable them to assist their child to improve in functioning.

20. Respite Care • Respite care is a service provided to individuals unable to care for themselves that are furnished on a short-term basis because of the absence or need for relief of those persons normally providing the care.

21. Therapeutic Activities • The focus of therapeutic activities is to interact with the child to accomplish the goals identified in the POS. • Service Activities include: • Music Therapy, • Recreation Therapy, and • Art Therapy.

22. Child Therapeutic Foster Care • Provides an intensive therapeutic living environment for a child with challenging behaviors. Important components of CTFC include: • Intensive parental supervision • Positive adult-youth relationships • Reduced contact with other children with behavioral disorders • Family behavior management skills

23. Therapeutic Overnight Camp • A group recreational and skill building service in a camp setting aimed at meeting goals detailed in the child’s plan of service. A session can be one or more days and nights of camp.

24. Transition Services • This is a one-time-only expense to assist a child returning to the family home and community while the family is in the process of securing other benefits (e.g. SSI) or resources (e.g., governmental rental assistance and/or home ownership programs) that may be available to assume these obligations and provide needed assistance.

25. Wraparound • Wraparound Service Facilitation and Coordination for Children and Adolescents is: • a highly individualized planning process • performed by specialized wraparound facilitators • coordinate the planning for, and delivery of, services and supports for the identified child

26. Currently participating

27. Participating CMH/Counties • CMH for Central Michigan (Isabella and Midland) • CMH Authority of Clinton-Eaton-Ingham Counties (Ingham) • Kalamazoo CMH Services • Livingston County CMH Authority • Macomb County CMH Services • Northern Lakes CMH Authority (Grand Traverse/Leelanau) • Saginaw County CMH Authority • Van Buren Community Mental Health Authority

28. Ages Of Children Served By SEDW

29. Desired Outcomes • Children are able to reside in the community with their families • Children have improved functioning across life domains • Maximized fiscal efficiencies across service systems

30. Systems Outcomes: Maximizing Fiscal Efficiencies • Identify and implement cost-effective opportunities to increase access to mental health services for children with SEDW • Maximize federal match dollars with local General Funds

31. Systems Outcomes: Maximizing Fiscal Efficiencies • Reduce impediments to improve local collaboration by: • Implementing a system of care • Streamline service opportunities • Use of braided funding

32. Falling Through the Cracks DHS EDUC CMH SA COURT

33. How does Wraparound Fit In? • Wraparound is a planning process: It is about ACTION • The planning process identifies strengths, needs, strategies (staffed services and non-staff items) and outcomes. • Wraparound utilizes a Child and Family Team with team members determined by the family, often representing multiple agencies, and informal supports. • The Child and Family Team creates a highly individualized plan for the child and family that consists of services and supports

34. Key Features • Child and Family Team • Team Facilitator • Strengths and normalized needs • Family access, voice and ownership • Unconditional • Cultural Competency • Creativity • Monitoring/evaluation: Outcome oriented • Community ownership • Community safety

35. Funding • Federal match funds to support collaborative service delivery in a child’s community • Billed “fee for service” by the responsible CMHSP

36. Projected Annual Waiver Costs vs. Hospitalization Costs

37. Local Funding • Mental Health/CMHSP General local funds • Child Care Fund (DHS/Court)

38. Why do Blended Braided Funding? • Helps your local system of care • Builds capacity and trust across systems • Cost share vs. Cost shift • Share gate-keeping of high need children • Bring additional state and federal revenue to your community • Make children eligible for Medicaid who would not otherwise be eligible

39. Things to Think About • Who are the underserved children in our community? • Who do we fight the most over trying not to serve? • What are their financial and personal eligibility characteristics SED/CMH, Court CCF-CW or JJ, DHS, Special Ed • Will the children meet the above eligibility criteria? • What percent are Medicaid eligible or CCF eligible?

40. Things to Think About • Will the children benefit from intensive community based services? • Do we have experience in providing intensive community based services? • Do we currently have wraparound available in our community? Do we have other funding to serve non-waiver eligible children • Do we currently blend/braid funds? • Do we have a community gate-keeping team?

41. The Child Care Fund

42. Child Care Fund • Cost share between state and county • County incurs expenses • State reimburses 50% (without limit) • Used to fund • Out of home costs • In-home community based care • While a large majority of Child Care Funds are for Juvenile Justice, 54% of the children are neglect/abuse

43. Child Care Fund • Local agencies develop contracts/agreements with county commissioners/administrators for services and identify $$$ • $$$ added to the CCF “Expanded” child care fund • Purchase reimbursable services for CCF eligible children • For every $100 spent locally, receive $50 back (50/50 match)

44. Considering CCF for Blended Funds? • Potential for matching state, federal and donated funds • Ability to use CCF for community programs • Local decisions to meet local needs

45. Eligible Youth – CCF In-Home Care • Delinquent Youth • Abuse/neglect Youth IF • A petition has been accepted by court • Abuse or neglect category I, II or III at risk of out-of-home placement

46. Eligible Programs - CCF In-Home Care • Programs must be intensive • Prevent need for out-of-home placement OR • Provide for an early return home from placement • Meet documentation and reporting requirements

47. Social Welfare Act (Excerpt) 400.117c • County treasurer as custodian of money; creation and maintenance of child care fund; deposits in fund; use of fund; separate account for fund; subaccounts; plan and budget for funding foster care services; records of juvenile services and expenditures; applicability of section to county juvenile agency. • (f) All funds made available to the county for the foster care of children from any other source, except gifts that are conditioned on a different disposition or reimbursement of the general fund

48. “Building a Collaborative Community budget, No It’s My Money”

49. Sources of Funding:Using CCF and SEDW $1 from County/CMH/UW $1 from State $2 CCF $2 CMH “State Share” $2 “Federal Share” $4 Total SEDW Effort

50. $1,140 Federal $860 $860 Contracts for $860 “Expanded” County Child Care Fund DCH State $430 Reimbursement Request DHS Child Care Fund and Medicaid CMH $2,000 $430 County $430 Commissioners