THE SKILL BUILDING CURRICULUM Module 7 Service Array and Financing

1. Primer Hands On-Child Welfare THE SKILL BUILDING CURRICULUM Module 7 Service Array and Financing Developed by: Sheila A. Pires Human Service Collaborative Washington, D.C. In partnership with: Katherine J. Lazear Research and Training Center for Children’s Mental Health University of South Florida, Tampa, FL Lisa Conlan Federation of Families for Children’s Mental Health Washington, D.C.

2. Why Focus on Medicaid Managed Care? • Medicaid is the primary source for health/mental health care for children in child welfare. • Most states (86%) are applying managed care approaches to their Medicaid programs. Health Care Reform Tracking Project 2003 State Survey. Research and Training Center for Children’s Mental Health, University of South Florida, Tampa, FL

3. Children in Child Welfare in Medicaid Managed Care Source: CMS/MSIS State Summary Data, FY 2003 53% - 72% of foster care population is enrolled in Medicaid managed care – HMO Enrollment: 245,313 BHO Enrollment: 174,584 ________________________ Total Enrollment: 419,897 Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

4. State Coverage of Child Welfare Population in Medicaid Managed Care Source: Health Care Reform Tracking Project 2003 State Survey • 26 states include the child welfare population in • Medicaid managed care – • 22 with mandatory enrollment • 4 with voluntary enrollment Pires, S. (2002). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

5. NRCOI Framework for a Full Service Array in Child Welfare “Collaborative, strategic, population-focused process, guided by set of tools, to identify array of practices, services, and supports needed in a SOC for child welfare populations” Assessment of Current Practices in the Jurisdiction as They Relate to Building Specified, Needed Child Welfare Capacities. Assessment of Current Leadership and Systemic Culture in the Jurisdiction as They Relate to Building Specified, Needed Child Welfare Capacities. Assessment of Current Services in the Jurisdiction as They Relate to Building Specified, Needed Child Welfare Capacities. Assessment of the Need for Other Services Not Currently Available in the Jurisdiction as They Relate to Building Specified, Needed Child Welfare Capacities. Preister, S. 2005. Assessing and enhancing the service array in child welfare. University of Southern Maine: National Child Welfare Resource Center for Organizational Improvement

6. Purposes of NRCOI Framework • Create a service directory • Prepare for the CFSR, the Statewide Assessment, and in • developing the PIP re the service array • Meet CAPTA requirement to conduct annual inventory • Help define array of services needed in SOC when • specific target population has been chosen • Identify gaps and strategies to improve service array • Can lead to better collaboration among providers and • a better functioning community collaborative Examples Pulaski, Co., Virginia Nebraska – 14-county rural area Preister, S. 2005. Assessing and enhancing the service array in child welfare. University of Southern Maine: National Child Welfare Resource Center for Organizational Improvement

7. PRIMER HANDS ON- CHILD WELFARE HANDOUT 7.1 National Child Welfare Resource Center for Organizational Improvement: Service Array Framework www.nrcoi.org Primer Hands On - Child Welfare (2007)

8. Dawn Services & Supports 2005 CHIOCES, Inc., Indianapolis, IN

9. Examples of Evidence Based Practices Related to CFSR Outcomes Programs Addressing Safety - Abuse-Focused Cognitive Behavioral Therapy (AF-CBT) - AMEND, Inc. (Abusive Men Exploring New Directions) - Child Parent Psychotherapy for Family Violence (CPP-FV): Domestic Violence Rated - Project Connect - Child Parent Psychotherapy for Family Violence (CPP-FV) – Trauma Treatment Rated - Project SafeCare - Domestic Abuse Intervention Project (DAIP) - Nurturing Parenting Programs - Project SUPPORT - Intensive Reunification Program (IRP) Motivational Interviewing (MI) - Nurturing Program for Families in Substance Abuse Treatment and Recovery - Parent-Child Interaction Therapy (PCIT) - Self-Motivation Group (SM Group) - Shared Family Care (SFC) - Supported Housing Program (SHP) - The Community Advocacy Project - Triple P – Positive Parenting Program Programs Addressing Permanency HOMEBUILDERS - Intensive Reunification Program (IRP) - Project CONNECT - Shared Family Care Programs Addressing Well-Being 1-2-3 Magic: Effective Discipline for Children 2-12 - Abuse-Focused Cognitive Behavioral Therapy -Alcoholics Anonymous (A.A.) - AMEND, Inc. (Abusive Men Exploring New Directions) - Child Parent Psychotherapy for Family Violence (CPP-FV): Domestic Violence Rated - Child Parent Psychotherapy for Family Violence (CPP-FV): Trauma Treatment Rated - Community Reinforcement + Vouchers Approach (CRA + Vouchers) - Community Reinforcement Approach - Domestic Abuse Intervention Project (DAIP) - Eye Movement Desensitization and Reprocessing (EMDR) - Intensive Reunification Program (IRP) - Motivational Interviewing (MI)Nurturing Parenting Programs - Nurturing Program for Families in Substance Abuse Treatment and Recovery - Parent-Child Interaction Therapy (PCIT) - Parenting Wisely - Project CONNECT - Project SUPPORT - Self-Motivation Group (SM Group) - Shared Family Care (SFC) - STEP: Systematic Training for Effective Parenting - Supported Housing Program (SHP) - The Community Advocacy Project - The Incredible Years – Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) - Triple P – Positive Parenting Program California Evidence-Based Clearinghouse at: http://www.cachildwelfareclearinghouse.org

10. Examples of Other Services You’d Want to Provide Based on Practice/Family Experience & Outcomes Data • Family Group Decision Making • Wraparound • Integration of natural helping networks • Intensive in-home services (not just MST) • Respite services • Mobile response and stabilization services • Independent living skills and supports • Family/youth education and peer support Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

11. Examples of What You Don’t See Listed as Evidence-Based Practice (though they may be standard practice) • Residential Treatment • Group Homes • Day Treatment • Traditional office-based “talk” therapy Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

12. 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

13. PRIMER HANDS ON- CHILD WELFARE HANDOUT 7.2 Examples of Potentially Harmful Programs and Effective Alternatives Source: Dodge, K., Dishion, T., & Lansford, J. (2006). “Deviant Peer Influences in Intervention and Public Policy for Youth,” Social Policy Report, Vol. XX, No. 1, January 2006. As published in Youth Today: The Newspaper on Youth Work, Vol. 15, No. 7. www.youthtoday.org Primer Hands On - Child Welfare (2007)

14. Challenges to Financing and Implementing Evidence-Based/Promising Practices Financing & Infrastructure needed for: Training Consultation Coaching Provider Capacity Development Fidelity Monitoring Outcomes Tracking Pires, S. 2005. Human Service Collaborative. Washington, D.C.

15. How to Finance/Implement Evidence-Based and Promising Practices Adopt a Population Focus: Who are the populations of families and youth for whom you want to change practice/outcomes? Adopt a Cross-Systems Approach: What other systems serve these children and families? Who controls potential or actual dollars? Which systems now spend a lot on restrictive levels of care with poor outcomes or on deficit-based assessments not linked to effective services - opportunities for re-direction? Identify Incentives and Supports to finance/implement evidence based practices Pires, S. 2005. Human Service Collaborative. Washington, D.C.

16. Examples of Incentives to Various Systems Serving Children and Families Medicaid: slowing rate of growth in inpatient, emergency room, residential treatment and pharmacy costs Child Welfare: meeting Adoptions and Safe Families Act outcomes; reducing out-of-home placements Juvenile Justice: creating alternatives to incarceration Mental Health: more effective delivery system Education: reducing special education expenditures Pires, S. 2005. Human Service Collaborative. Washington, D.C.

17. Examples of Cross-System Partnerships to Finance and Implement Evidence-Based and Promising Practices District of Columbia Multi Systemic Therapy (MST), Mobile Response, In-Home Medicaid Rehab Optionto pay for MST, Intensive Home-Based Services (Ohio model), Mobile Response and Stabilization Services (NJ model) Child Welfareprovided match and paid for initial training, coaching, provider capacity development; Mental health/child welfare to share costs of outcomes tracking Juvenile Justicealso to pay match, training costs as well Medicaid HMOexpressing interest in Mobile Crisis Pires, S. 2005. Human Service Collaborative. Washington, D.C.

18. Service Array Focused on a Total Population Universal Targeted • Family Support Services • Youth Development Program/Activities • Service Coordination • Intensive Service Management • Wraparound Services & Supports; Family Group Decision Making Core Services Prevention Early Intervention Intensive Services Pires, S. & Isaacs, M. (1996, May) Service delivery and systems reform. [Training module for Annie E. Casey Foundation Urban Mental Health Initiative Training of Trainers Conference]. Washington, DC: Human Service Collaborative.

19. Characteristics of a Culturally and Linguistically Competent Service Design & Practice • Driven by family/youth-preferred choices; • Understands the needs/help-seeking behaviors of youth/families; • Embraces principles of equal access/non-discriminatory practices; • Designs/implements services and supports that are tailored or matched to the unique needs of children, youth, families, organizations and communities served; • Recognizes well-being crosses life domains; • Understands that cultural competence must be defined and required for Evidence Based Practices (EBP), and that Practice Based Evidence (PBE) must be taken into consideration as a critical component of EBPs in communities of color. Lazear, K. J Primer Hands On Human Service Collaborative, Washington, DC. 2006

20. Families and Youth Provide Valuable Services and Supports • As technical assistance providers & consultants • Training • Evaluation • Research • Support • Outreach • As direct service providers • Foster Parents • Mentors • Service Coordinators • Family Educators • Specific Program Managers (respite, etc) Adapted from Wells, C. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

21. Family and Youth Roles in Building Evidence-Based Practice (EBP) • Advocate for ethical, culturally sensitive research • Participate in the development and analysis of research to support EBP • Assist in data collection to support EBP • Educate families, family leaders and youth about EBP Wells, C. & Pires, S. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

22. Examples of Strategies to Address Lack of Home and Community-Based Services • Support family and youth movements • Engage natural helpers and culturally diverse communities • Implement a meaningful Medicaid rehab option • Write child and family appropriate service definitions • Collapse out-of-home and home and community-based budget structures • Re-direct dollars from out-of-home to home and community-based • Implement flexible rate structures (e.g., bundled rates/case rates) • Implement pilots or phase in system change Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

23. Examples of Strategies to Address Lack of Home and Community-Based Services • Implement capacity-building grants • Implement performance-based contracts • Develop practice and implementation guidelines • Train providers, judges, families, etc. – use training resources across systems • Implement quality and utilization management • Apply for federal demonstration grants • Collect data on child and family outcomes, family/youth satisfaction, and cost/benefits • Educate key constituencies (e.g., legislators, Governor’s Office, State Insurance Commissioner) Pires, S. 2005. Building systems of care..Human Service Collaborative. Washington, D.C.

24. Examples of Sources of Funding for Children/Youth with Individualized Needs in the Public Sector • Education • ED General Revenue • ED Medicaid Match • Student Services • Medicaid • Medicaid In-Patient • Medicaid Outpatient • Medicaid Rehabilitation Services Option • Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT) • Targeted Case Management • Medicaid Waivers • TEFRA Option • Mental Health • MH General Revenue • MH Medicaid Match • MH Block Grant • Other • TANF • 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 funding for children & families in the public sector. Washington, DC: Human Service Collaborative.

25. Major Child Welfare Funding Streams • Child Welfare Services – Title IV-B • Foster Care & Adoption Assistance – Title IV-E • Social Services Block Grant • Temporary Assistance to Needy Families (TANF) • Medicaid – Title IX • State and local general revenue Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

26. Advantages and Drawbacks of Specific Child Welfare Financing Streams Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

27. Creating “Win-Win” Scenarios Child Welfare Medicaid Alternative to out-of-home care high costs/poor outcomes Alternative to Inpatient/Emergency Room-high cost System of Care Alternative to detention-high cost/poor outcomes Alternative to out-of-school placements – high cost Juvenile Justice Special Education Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

28. Thinking Across Systems Serving Children, Youth and Families Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

29. Financing Strategies to Support Improved Outcomes for Children, Youth and Families FIRST PRINCIPLE: System Design Drives Financing Friedman, M. (1995). Financing strategies to support improved outcomes for children. Washington, DC: Center for the Study of Social Policy.

30. What Are the Pooled Funds? 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) • MENTAL HEALTH • Crisis Billing • Block Grant • HMO Commercial Insurance 9.5M 8.5M 10M 2.0M Wraparound Milwaukee Management Service Organization (MSO) $30M Per Participant Case Rate Provider Network 240 Providers 85 Services Care Coordination Child and Family Team Plan of Care Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and Adolescent Services Branch.

31. Example: Pooled Funds for Nebraska’s Integrated Care Coordination Units Child Welfare State General Revenue, IV-E, IV-B Juvenile Justice State General Revenue Federal Mental Health Block Grant Case Rate Integrated Care Coordination Unity Services and supports for children in state custody with complex needs Families Care 8% of Case Rate Pires, S. (2007) Primer Hands On - Child Welfare

32. Financing – Cuyahoga County (Cleveland) System of Care Oversight Committee County Administrative Services Organization FCFC $$ Fast/ABC $$ Residential Treatment Center $$$$ Therapeutic Foster Care $$$ “Unruly”/shelter care $ Tapestry $$ SCY $$ State Early Intervention and Family Preservation } } System of Care Grants Neighborhood Collaboratives & Lead Provider Agency Partnerships Reinvestment of savings Community Providers and Natural Helping Networks Pires, S. (2006). Primer Hands On – Child Welfare. Washington, D.C.: Human Service Collaborative.

33. Example of Redirecting Funds Youth who are at-risk of entering a RTC Medicaid Federal and State (MHS Match DHR and DJS Mental Hygiene Block Money Youth referred to a local management entity $ $ $ At risk pool is created for the local management entities $ The three sources of funding stream into the local management entity from the state and federal government. The local management entity is held accountable to the state. The three sources of funding are from Medicaid, Mental Hygiene, and a combination of DHR and DJS. Local Management Entity Controls the management of treatment services, support services, and housing/placements. Money form the three funding sources are streamlined into the local management entity Treatment services (in patient (treatment facility) and out-patient (in-home) services) Support services (respite, behavioral supports, nutrition, etc.) Housing/Placement services(foster care, group home, adoption, etc.) Adapted from State of Maryland, 2004

34. Where to Look for Money and Other Types of Support e e Pires, S. (1994). Where to look for money and other types of support. Washington, DC: Human Service Collaborative.

35. Diversity of Federal Grant Sites Funding 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.

36. Diversity of Federal Grant Sites Funding (continued) CMHS GRANT SITES FUNDING 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.

37. Diversity of Federal Grant Sites Funding (continued) 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.

38. Example: Diversified Funding Sources & Approaches at the Parent Support Network, RI STATE APPROPRIATION FUNDS BEHAVIORAL HEALTH CHILD WELFARE IVB FUNDS DEPARTMENT OF EDUCATION DISCRETIONARY FUNDS FEDERAL GRANTS & PRIVATE DONATIONS Administrative Infrastructure (4.0 FTE) Executive Director, Assistant Director, Administrative Assistant, and Data and Technology Specialist Peer Mentor Program (3.25 FTE) Information & Referral Child & Family Teams Education Planning Support Groups/ Youth Speaking Out Training Family & Youth Leadership Program (2.50 FTE) System Reform Training & TA Placement on Policy Boards Focus Groups Social Marketing/ Presentations Conlan (2007). Parent Support Network of Rhode Island Infrastructure and Primary Funding Sources.

39. Examples of Medicaid Options States Use to Cover Evidence-Based and Promising Community-Based Practices (1) Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

40. Examples of Medicaid Options States Use to Cover Evidence-Based and Promising Community-Based Practices (2) Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

41. Examples of Medicaid Options States Use to Cover Evidence-Based and Promising Community-Based Practices (3) Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

42. Bottom Line State Medicaid agencies are cobbling together a variety of Medicaid options in attempt to cover and contain community-based services for children and families - often without involvement of other systems serving children and families. What is needed is a more integrated, strategic financing approach across systems. Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

43. If you have answered the questions: Financing For Whom? Financing for What? • I.E., • Identified your population(s) of focus • Agreed on underlying values and intended outcomes • Identified services/supports and practice model to achieve outcomes • Identified how services/supports will be organized (so that all key stakeholders can draw the system design) • Identified the administrative/system infrastructure needed to support the delivery system • Costed out your system of care Then You Are Ready To Talk About Financing! Pires, S. 2006. Human Service Collaborative. Washington, D.C.

44. Strategic Financing Analysis • Identify state and local agencies that spend dollars on the identified population(s). (How much each agency is spending and types of dollars being spent, e.g., federal, state, local, tribal, non-governmental) • Identify resources that are untapped or under-utilized (e.g., Medicaid). • Identify utilization patterns and expenditures associated with high costs/poor outcomes, and strategies for re-direction. • Identify disparities and disproportionality in access to services/supports, and strategies to address. • Identify the funding structures that will best support the system design (e.g., blended or braided funding; risk-based financing; purchasing collaboratives). • Identify short and long term financing strategies (e.g., Federal revenue maximization; re-direction from restrictive levels of care; waiver; performance incentives; legislative proposal; taxpayer referendum, etc.). Pires, S. 2006. Human Service Collaborative. Washington, D.C.

45. Example: Program Budget for a Neighborhood-Based System of Care GRAND TOTALS: 1,115,100 80,000 125,900 459,900 84,300 51,100 64,100 45,800 55,300 36,800 113,900 Pires, S. (2002). Building systems of care: A primer. Human Service Collaborative: Washington, D.C. Adapted from Abriendo Puertas Family Center.

46. Example: Program Budget for a Neighborhood-Based System of Care (continued) Revenue Allocation By Program Pires, S. (2002). Building systems of care: A primer. Human Service Collaborative: Washington, D.C. Adapted from Abriendo Puertas Family Center.

47. PRIMER HANDS ON- CHILD WELFARE HANDOUT 7.3 The “Matrix” from Oregon How to Fund the Service Array and How to Process Includes: Client Related Expenditures Resource Priorities Payment Documents Primer Hands On - Child Welfare (2007)