7/8/2014. Prevalence/Utilization Triangle. Setting the Context. Children in Medicaid Using BH Care: A High Cost Population

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1 Georgetown University 2014 Training Institutes Customizing Care Coordination in Medicaid Delivery Systems for Children with Serious Behavioral Health Challenges: The Use of Care Management Entities and Wraparound Teams Setting the Context PRESENTERS Sheila A. Pires Senior Partner, Human Service Collaborative; Core Partner, Technical Assistance Network Jody Levison Johnson Deputy Assistant Secretary, Louisiana Office of Behavioral Health Elizabeth Manley Director, System of Care Division, New Jersey Dept. of Children and Families Why Children with Significant Behavioral Health Challenges Need Customized Care Coordination Jackie Shipp Director, Community Based Services, Oklahoma Dept. of Mental Health and Substance Abuse Services Dayana Simons Senior Program Officer, Center for Health Care Strategies, Inc.; Core Partner, Technical Assistance Network Michelle Zabel University of Maryland Baltimore, Institute for Innovation and Implementation; Lead Core Partner, Technical Assistance Network 2 Mental Health = Costliest Health Condition of Childhood Children in Medicaid Using BH Care: A High Cost Population BILLIONS of Dollars $30.00 $25.00 $20.00 $15.00 $10.00 $5.00 $0.00 $8.90 $8.00 $6.10 $3.10 $2.90 Mental Health Disorders Asthma Trauma Related Conditions Acute Bronchitis Infectious Diseases Mean Medicaid expenditures (PH and BH) = $8,520 per year Nearly 5x higher than for Medicaid children in general ($1,729 per year*) TANF enrolled children nearly 3x higher Foster care 7x higher SSI/disabled nearly 9x higher Expenditures driven more by behavioral rather, than physical health service use, except for children on SSI/disability who have slightly higher physical health expense Children with top 10% of BH expense are 28x more expensive than Medicaid children in general *As estimated in Center for Medicaid and State Operations: Statistical Report on Medical Care: Eligibles, Recipients, Payments, and Services (HCFA 2082), MSIS Statistical Supplement. Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid: Examining Children s Behavioral Health Service Use and Expenditures. Hamilton, NJ; Center for Health Care Strategies 3 Source: Soni, 2009 (AHRQ Research Brief #242) 4 Children in Foster Care Use More Restrictive, More Expensive Services in Medicaid Prevalence/Utilization Triangle More likely to use: Inpatient psychiatric services Residential treatment Therapeutic group care Emergency room services Psychotropic medications One fifth the size of the TANF population, but use: Nearly the same amount of dollars for residential, group care and ER visits 3.5 times more for therapeutic foster care More complex needs Less complex needs 2-5% 15% 80% Intensive Services 60% of $$ Home & community services and supports; early intervent n 35% of $$ Prevention and Universal Health Promotion 5% of $$ Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid: Examining Children s Behavioral Health Service Use and Expenditures. Hamilton, NJ; Center for Health Care Strategies Pires, S Human Service Collaborative. Washington, D.C

2 Children and Youth with Serious Behavioral Health Conditions: Distinct Population from Adults with Serious and Persistent Mental Illness Do not have the same high rates of co morbid physical health conditions as adults with SPMI Have different mental health diagnoses from adults with SPMI (i.e. ADHD, Conduct Disorders, Anxiety); not as much Schizophrenia, Psychosis, Bipolar; and diagnoses change often Two thirds are typically involved with child welfare and/or juvenile justice systems, and 60% may be in special education systems governed by legal mandates Care coordinator s time is primarily spent on coordination with other children s systems (i.e. child welfare, juvenile justice, schools), behavioral health providers, family needs/concerns, not coordination with primary care To improve cost and quality of care, focus must be on child and family/caregiver(s) which takes time Customized, Intensive Care Coordination Approaches Are Needed Traditional case management and care coordination approaches for adults are not sufficient Need for: Lower case ratios Higher payment rates Approach based on evidence of effectiveness Pires, S. March 2013 Customizing Health Homes for Children with Serious Behavioral Health Challenges. Human Service Collaborative 7 8 Customized Care Coordination Approaches for Children with Serious Behavioral Health Challenges Care Management Entities Organizations providing intensive care coordination at low ratios (1:10) using high quality Wraparound* care planning approach High Quality Wraparound Teams embedded in supportive organization, such as CMHC, FQHC or school based mental health center, providing intensive care coordination at low ratios Growing number of states experiencing better outcomes, lower per capita costs. (MA, LA, NJ, WI, IL; PRTF Waiver Demo states; CHIPRA Care Management Entity Quality Collaborative states(md, GA, WY); OK) (*May 7, 2013 CMCS SAMHSA Joint Informational Bulletin) Important Points About Wraparound Wraparound is: A defined, team based service planning and coordination process A structured approach to service planning and care coordination It is NOT a service per se The Wraparound care planning process ensures that there is one coordinated plan of care and one care coordinator The ultimate goal is to improve: Outcomes Family and youth experience with care Per capita costs of care health care s triple aim 9 Pires, S Washington DC: Human Service Collaborative 10 What s Different in Wraparound? High quality teamwork Collaborative activity Brainstorming options Goal setting and progress monitoring The plan and the team process is driven by and owned by the family and youth Taking a strengths based approach The plan focuses on the priority needs as identified by the youth and family Focus on: Whole youth and family Developing optimism and self efficacy Developing enduring social supports In wraparound, a care coordinator coordinates the work of system partners and other natural helpers so there is one coordinated plan Behavioral Health Natural Supports Extended family Neighbors Friends Juvenile Justice Care Coordinator (+ Peer Partner) Education FAMILY YOUTH Child welfare Health care Community Supports Neighborhood Civic Faith based 11 ONE PLAN Adapted from Laura Burger Lucas, ohana coaching,

3 Wraparound is Increasingly Considered Evidence Based State of Oregon Inventory of Evidence Based Practices (EBPs) California Clearinghouse for Effective Child Welfare Practices Washington Institute for Public Policy: Full fidelity wraparound is a research based practice Costs and Residential Outcomes are Robust CMS Psychiatric Residential Treatment Facility (PRTF) Waiver Demonstration (Urdapilleta et al., 2011) Average per capita saving by state ranged from $20,000 to $40,000 Los Angeles County Department of Social Services Found 12 month placement costs were $10,800 for Wraparound discharged youths compared to $27,400 for matched group of RTC youths Wraparound Milwaukee Reduction in placement disruption rate in child welfare from 65% to 30% School attendance for child welfare involved children improved from 71% days attended to 86% days attended 60% reduction in recidivism rates for delinquent youth from one year prior to enrollment to one year post enrollment Decrease in average daily pop. in residential treatment centers from 375 to 50 Reduction in psychiatric inpatient days from 5,000 days per year to <200 Average monthly cost of $4,200 (compared to $7,200 for RTC, $6,000 for juvenile detention, $18,000 for psychiatric hospitalization) Maine Experienced 30% net reductions in Medicaid spending, comprised of decreases in PRTF and inpatient psychiatric with increases in targeted case management and home and community based services Child and Youth Populations Typically Served by CMEs/High Quality Wraparound Teams Children and adolescents: With serious emotional/behavioral challenges at risk of outof home placement in residential treatment, group homes, and other institutional settings Returning from institutional placements in residential treatment, correctional facilities, or other out of home setting At risk of or returning from psychiatric inpatient settings in child welfare Youth at risk of incarceration or placement in juvenile correctional facilities Detention diversion and alternatives to formal court processing for juveniles Other populations (e.g., youth at risk for alternative school placements) 15 Pires, S Human Service Collaborative Customization Strategies Regardless of Medicaid System Design Customized Care Coordination (May 7, 2013 CMCS and SAMHSA Informational Bulletin) Incorporate intensive care coordination using Wraparound approach for children with serious behavioral health challenges (growing number of states MA, LA, NJ; PRTF Waiver Demo; CHIPRA Care Management Entity Quality Collaborative states) Intensive care coordination rates for this population range from $780 pmpm to $1300 pmpm (CHCS Matrix) In fidelity intensive care coordination/wraparound approaches, all inclusive cost of care (e.g., admin, care coord, placements, clinical treatment, informal supports) averages $3700 $4200 pmpm (about $2100 is Medicaid ) compare to $9,000 pmpm in PRTFs, higher in psych inpatient 16 Pires, S. & Stroul, B Making Medicaid Work for Children in Child Welfare. Hamilton, NJ: Center for Health Care Strategies Care Management Entity Functions Variation in Types of CME Entities Service Level Child and family team facilitation using fidelity wraparound practice model Screening, assessment, clinical oversight Intensive care coordination Care monitoring and review Peer support partners Access to mobile crisis supports Administrative Level Information management real time data; web based IT Provider network recruitment and management (including natural supports) Utilization management Continuous quality improvement; outcomes monitoring Training Public agency as CME Wraparound Milwaukee New non profit organization with no other role New Jersey Care Management Organizations Existing non profit organization with other direct service capability Massachusetts Community Service Agencies Hybrid Non profit organization with other direct service capability in formal partnership with neighborhood organization Cuyahoga County, OH Coordinated Care Partnerships Non profit HMO Massachusetts Mental Health Services Program for Youth 17 Pires, S Human Service Collaborative 18 Pires, S Human Service Collaborative 3

4 Integration at the Systems/Medicaid Purchaser Level: Caveats Research has shown that When adult and child behavioral health dollars are integrated, there is a risk of child behavioral health dollars being absorbed by adult services When physical and behavioral health dollars are integrated, there is a risk of behavioral health dollars being absorbed by physical health services Especially in the absence of customization within the design for children with serious BH challenges, risk adjustment strategies, strong contractual performance measures and monitoring mechanisms Medical Homes All children Medical Homes vs. Health Homes Coordination of medical care Physician led primary care practices Health Homes Children with chronic health conditions, children with serious behavioral health conditions Coordination of physical, behavioral, and social supports Specialty provider organizations, including behavioral health specialty organizations (e.g., not only medical) 19 See publications and issue briefs published by the Health Care Reform Tracking Project at: hctrkprod.htm 20 Analysis of Medical Home Services for Children with Behavioral Health Conditions All behavioral health conditions except ADHD are associated with difficulties accessing specialty care through a medical home The data suggest that the reason why services received by children and youth with behavioral health conditions are not consistent with the medical home model has more to do with difficulty in accessing specialty care than with accessing quality primary care. Sheldrick, RC & Perrin, EC. Medical home services for children with behavioral health conditions. Journal of Developmental Pediatrics, 2010 Feb Mar 31 (2) 92 9 There is a need for more customized, intensive care coordination approaches for children with significant behavioral health challenges. Integration with Primary Care in a Wraparound Approach Ensuring child has an identified primary care provider (PCP) Tracking of whether child receives EPSDT screens on schedule Ensuring child has at least an annual well child visit Communicating with PCP opportunity to participate in child and family team and ensuring PCP has child s plan of care and is informed of changes Ensuring PCP has information about child s psychotropic medication and that PCP monitors for metabolic issues such as obesity and diabetes 21 Pires, S Washington DC: Human Service Collaborative 22 Pires, S Customizing Health Homes for Children with Serious Behavioral Health Challenges. Hamilton, NJ; Center for Health Care Strategies Accountable Care Organizations I believe, with some exceptions, ACOs will not succeed it will be difficult for anything but an organization that has been at it a long time to develop the team culture needed to be an ACO The reason that patient centered medical homes will not succeed is that health care follows the 80/20 rule 20% of patients generate 80% of the costs. Those 20% are the chronically ill, and I don t see how primary care physicians serving those patients add value to their care. Focused factories of care that is a term I use for provider organizations that deliver highly specialized care for a certain group of patients, such as those with diabetes you need specialists for that. They are the opposite of ACOs that do everything for everyone. Regina Herzlinger, Harvard Business School, as quoted in Managed Care Magazine Online ( REALITY: Care coordination ratios within Medicaid ACOs for the highest need run 1: Medicaid Vehicles to Support Customized Intensive Care Coordination Using Fidelity Wraparound With population pmpm case rate or with care coordination pmpm rate 1915(a) Wraparound Milwaukee, Children Come First (Dane Co WI) Targeted Case Management NJ, MA 2703 Health Home SPA OK (for SED), NJ (for subset of children with SED and co occurring medical or developmental conditions 1915(b) or (c) LA 1915(i) MD Money Follows the Person (GA) Balancing Incentive Program (GA) CMMI Health Innovations Grant (CHCS and 4 state application) 23 Pires, S Washington DC: Human Service Collaborative 24 Pires, S Human Service Collaborative: Washington DC 4

5 State Examples Intensive Care Coordination/Wraparound Structures How Embedded within Medicaid Delivery System Medicaid Vehicles Used Populations Served Customizing Care Coordination The Louisiana Experience July 17 & 19, 2014 OVERVIEW 28 Louisiana Coordinated System of Care The Coordinated System of Care (CSoC) is an initiative to serve Louisiana s youth with significant behavioral health challenges who are in highest need and at greatest risk. CSoC is a component of the Louisiana Behavioral Health Partnership. CSoC is a philosophy and approach to service delivery that results in improved integration and coordination, enhanced service offerings and improved outcomes. At full implementation the CSoC will serve 2400 youth. Specific goals for the CSoC include decreasing the number of youth in residential/detention settings, reduction in the state's cost for providing services by leveraging Medicaid and other funding sources, and improving the overall outcomes for these children/youth and their caregivers. Louisiana Department of Health and Hospitals Office of Behavioral Health 29 CSoC Implementing Regions Caddo DeSoto Bossier Webster Sabine Red River Beauregard Calcasieu Natchitoches Vernon Cameron Claiborne Bienville Allen Jefferson Davis Lincoln Jackson Winn Grant Union Rapides Ouachita Caldwell Morehouse West East Carroll LaSalle Catahoula Avoyelles Richland Franklin Tensas Concordia Madison Region 8 Shreveport; WAA = Choices David Sikes, , DSikes@choicesteam.org (Bienville, Bossier, Caddo, Claiborne, DeSoto, Jackson, Natchitoches, Red River, Sabine, Webster) Region 9 Monroe; WAA = Wraparound of Northeast Louisiana Curtis Eberts, , ceberts@thewraparound.org (Caldwell, East Carroll, Franklin, Lincoln, Madison, Morehouse, Richland, Ouachita, Tensas, West Carroll) Region 7 Alexandria; WAA = Eckerd Jodie Roberts; , roberts@eckerd.org (Avoyelles, Catahoula, Concordia, Grant, LaSalle, Rapides, Vernon, Winn) Region 2 Baton Rouge; WAA = National Child and Family Services (NHS) Carolina Jones, LCSW, , cjones02@nhsonline (Ascension, East Baton Rouge, East Feliciana, Iberville, Livingston, Pt. Coupee. West Baton Rouge, West Feliciana) Region 1 Greater New Orleans; WAA = National Child and Family Services (NHS) Karen Davis, Ph.D., LPC, LMFT, , kdavis02@nhsonline.org (Jefferson, Orleans, Plaquemines, St. Bernard) St. West East Washington Helena Statewide FSO: Evangeline Pt. Feliciana Ekhaya Youth Project Coupee Tangipahoa Darrin Harris, dharris@ekhaya4youth.org, East St. Landry W x577 Baton Rouge Livingston St. Tammany Acadia St. Martin Orleans Lafayette Iberville Ascension St. St. James John St. Iberia Assumption Vermilion s Charles Lafourche St. Bernard St. Mary Jefferson Terrebonne Plaquemines 30 5

6 Intensive Care Coordination / Wraparound Structure in Louisiana Department of Health & Hospitals Office of Behavioral Health Medicaid Statewide Management Organization (SMO) STRUCTURES Wraparound Agencies Family Support Organization Provider Network 31 Louisiana Department of Health and Hospitals Office of Behavioral Health 32 Medicaid Vehicles in Louisiana CMS Authority: 1915(b) Waiver allows for the use of Managed Care in the Medicaid Program 1915(c) Waiver allows for the provision of long term care services in home and community based settings under the Medicaid Program Wraparound Agencies: administrative payment Peer Support Services (Youth & Parent): Fee for service payment Population Served in Louisiana Age 21 or under DSM diagnosis or exhibiting behaviors indicating a behavioral health diagnosis may exist Meets clinical eligibility on the CANS Comprehensive Generally involved with multiple child serving systems In or at risk of out of home placement Louisiana Department of Health and Hospitals Office of Behavioral Health 33 Louisiana Department of Health and Hospitals Office of Behavioral Health 34 Keeping Families Strong Keeping Children Safe and Well 35 6

7 Children s System of Care Objectives To help youth succeed Children s System of Care Presented by Elizabeth Manley Division Director At Home Successfully living with their families and reducing the need for out-of-home treatment settings. In School Successfully attending the least restrictive and most appropriate school setting close to home. In the Community Successfully participating In the community and becoming independent, productive and law-abiding citizens. 38 Children s System of Care Values and Principles Strength Based Unconditional Care Promoting Independence Child Centered & Family Driven Community Based Culturally Competent Family Involvement Collaborative Cost Effective Comprehensive Individualized Home, School & Community Based Team Based 39 Financing Rehab Option Child Welfare and Juvenile Justice Targeted Case Management 1915 like (i) or (c) 1115 Waiver CHIP/SCHIP State Funds Priorities Serve More EBPs Care Management System Coordination Reduce Institutional Care Particular Populations CSOC Values & Final System of Care Design Principles Environment Political Perspectives of Leaders Law Suits/Settlements Crisis/Tragedy Mandates Community Will Economic Factors That impact Design Structure Government State vs. County Existing Reality Envisioned Ideal Medicaid Agency Locus of Control Leadership Structure 40 Key System Components Role of Contracted Systems Administrator (CSA) Contracted System Administrator Care Management Organization Mobile Response & Stabilization Services Family Support Organization Intensive In Community Out of Home DD Family Support Services Substance Abuse Treatment Services CSA is the single portal for access to care available 27/7/365 Care Management Organization utilizing a wraparound model of care serving youth with complex and moderate and their families Crisis response and planning available 24/7/365 Family led support and advocacy for parents and caregivers and youth Flexible, multi purpose, in home/community clinical support for parents/caregivers and youth with behavioral and emotional disturbances who are receiving care management, MRSS, or out f home services Full continuum of residential treatment / out of home care Supports, services, resources, and other assistance designed to maintain and enhance the quality of life of a young person with developmental disability and his or her family, including respite services and assistive technology Out of home and outpatient substance abuse treatment services (limited) CSA creates pathways for youth and young adults by providing access to the right care at the right time. CSA authorizes services, based on the most recent clinical information that is submitted to them. CSA does not provide direct services. Anyone helping children and families may contact CSA on behalf of a youth in need of a referral. However, the parent/legal guardian of the youth must give consent for services. CSA has a dedicated child welfare unit Traditional Services Partial Care, Partial Hospitalization, Inpatient and Outpatient services

8 The Role of Assessment within CSOC The vision of CSOC is to create positive outcomes for children with emotional and behavioral needs and those with intellectual and developmental disabilities by: Identifying the child and family s needs Determining the most appropriate Intensity of Service Delivering the most appropriate services for the most appropriate length of time Using standard assessment tools -- the foundation of the Children s System of Care. Positive Outcomes Appropriate Length of Stay Appropriate Services Appropriate Intensity of Service Child and Family Needs Assessment Tools Intensities of Service (IOS) Inpatient Treatment Out of Home Treatment Care Management Organization (CMO) Mobile Response & Stabilization Services Intensive In Community (IIC) & Behavioral Assistance (BA) Services Outpatient Treatment Assessment Services Access / Triage and Information and Referral (PerformCare) Care Management Care Management Organizations (CMO S) Utilize Child Family Teams (CFT s) within Wraparound Model to facilitate a planning process to address the individualized needs of each youth. NJ Department of Children and Families New Jersey Department of Children and Families Commissioner Division of Children s System of Care (formerly DCBHS) Division of Child Protection & Permanency (formerly DYFS) Division of Family & Community Partnerships (formerly DPCP) Division on Women Office of Adolescent Services Oklahoma Systems of Care

9 Children and Youth Served Children and youth* Up to age 22 With SED or co occurring disorder At risk of out of home or out of school placements With complex needs served by multiple agencies *Up to age 26 at Healthy Transitions Sites Care Coordination Care coordination in the wraparound process is designed to facilitate a collaborative relationship among the child with SED, the family and all systems involved. The Care Coordinator ensures that the wraparound process is organized and integrated across all child serving systems to enable the child to remain in his/her own home community. Wraparound In Oklahoma Wraparound teams (Care Coordinator and FSPs) are trained, coached and credentialed through the well established process managed by the ODMSHAS. Mandatory ODMHSAS sponsored/conducted trainings include: SOC Wraparound 101 Training: This is an introductory two day training focusing on the principles and values of Wraparound. It is an in depth look at the phases of Wraparound and teaches participants how to complete the necessary components including Strengths, Needs, Culture, Discovery (SNCD) assessments, functional assessments, crisis/safety plans, Wraparound plans, and other items. SOC Family Support Provider Training is required for FSPs Rehab Option of State Plan Amendment. Role in Wraparound HCPC Code Rate Timeframe Behavioral Health Aide H2019 $ minutes Family Support Provider H minutes Care Coordinator (TCM) bachelor s T minutes Care Coordinator (TCM) LBHP T minutes

10 State Context: Massachusetts Customizing Care Coordination in the Medicaid Delivery System for Children with Serious Behavioral Health Challenges In Massachusetts Targeted Institute #3 Georgetown Training Institutes Dayana Simons, M.Ed. LMHC Services are delivered through statewide system (not county based) Direct services are delivered primarily by contracted agencies There is the greatest concentration of teaching hospitals in the U.S. Medicaid managed care state July 2014 Adapted from Massachusetts Executive Office of Health and Human Services 56 System of Care/Wraparound Timeline The Massachusetts Catalyst: Rosie D s: Federal CASSP Grants 1998: RWJ Mental Health Services Program for Youth (MHSPY) 2003: WCC incorporated into to Coordinated Family-Focused Care (CFFC), which together with MHSPY, served ten cities and towns through Medicaid Waiver Federal Class Action Lawsuit (2001) on behalf of children and youth with serious emotional disturbance Final judgment issued July, : Parent/Professional Advocacy League (PPAL - state organization of the Federation of Families for Children s Mental Health) 1999: SAMHSA SOC Grants to Worcester Communities of Care (WCC) MassHealth, found to be out of compliance with reasonable promptness and Early Periodic Screening Diagnosis and Treatment (EPSDT) provisions of federal Medicaid law Adapted from Massachusetts Executive Office of Health and Human Services Adapted from Massachusetts Executive Office of Health and Human Services Statewide Implementation of: Standardized BH screening in primary care The Remedy Standardized scope of BH assessment, using the Child and Adolescent Needs and Strengths (CANS) tool New home and community based BH services, including intensive care coordination with high quality wraparound MassHealth (Office of Medicaid) MassHealth Managed Care Entities Primary Care Clinician (PCC) Plan (medical)/massachusetts Behavioral Health Partnership (MBHP) (behavioral health carve out) Health New England Be Healthy Neighborhood Health Plan Access to Services & Supports: Medicaid Managed Care in MA Managed Care Program Boston Medical Center HealthNet Plan Fallon Community Health Plan Network Health (medical and behavioral health) Adapted from Massachusetts Executive Office of Health and Human Services Massachusetts Behavioral Health Partnership (MBHP) (behavioral health) Beacon Health Strategies (behavioral health)

11 Massachusetts 1115 Waiver, State Plan (TCM) Massachusetts Definition of Intensive Care Coordination (Targeted Case Management) State Medicaid Agency (MassHealth) Purchaser MCO MCO MCO MCO BHO MCO Standardized tools for screening and assessment by PCPs CANS Community Services Agencies (CSA) Non Profit BH and Specialty Providers (Locally Based Care Management Entities) PCCM Includes: Assessment Development of an Individual Care Plan Referral and related activities Monitoring and follow up activities All of which is done using a high quality wraparound care planning process Massachusetts Populations Served in Intensive Care Coordination All children under the age of 21, and enrolled in MassHealth Standard or CommonHealth with: A diagnosis of SED as defined by SAMHSA OR The Individuals with Disabilities Education Act (IDEA) And: Needs or receives multiple services other than ICC from the same or multiple provider(s) Or: Needs or receives services from, state agencies, special education, or a combination thereof; And: Needs a care planning team to coordinate services the youth needs from multiple providers or state agencies, special education, or a combination thereof Maryland s Approach Michelle Zabel, MSS Director & Clinical Instructor, The Institute for Innovation & Implementation Director, The Technical Assistance Network for Children s Behavioral Health (TA Network) mzabel@ssw.umaryland.edu The Institute for Innovation & Implementation 66 11

12 Maryland: 1115 Waiver & Behavioral Health Carve Out; 1915(i) SPA in submission process Children s Cabinet + Governor s Office for Children, Maryland Department of Disabilities, Department of Budget & Management Children s Cabinet Interagency Fund Department of Human Resources (child welfare) Individual Agency Funds & Federal Grant Funds Department of Juvenile Services Maryland State Department of Education Administrative Service Organization Standardized Assessment Tools: CANS is used throughout the system for care planning; CASII is used for eligibility for the 1915(i) & will be used for PRTF level of intensity determinations Department of Health & Mental Hygiene (including Medicaid) 1115 Waiver Managed Care Organizations Pending 1915(i) SPA & TCM SPA Somatic Primary Public Mental Health Mental Intensive Care Coordination using Health System Care, Health Wraparound Practice Model (specialty) incl. Oral Services Health (nonspecialty) ***All children with Medicaid (Medicaid, CHIP, CHIP Premium, State Custody, Family of One) have an MCO and access to the full Public Mental Health System (access to those services for which they meet medical necessity criteria) The Institute for Innovation & Implementation 67 Funder Current/Proposed Funding Mechanisms CME Governor s Office for Children on behalf of the Children s Cabinet CCO (proposed) Medicaid through State Plan Amendments for Targeted Case Management (and 1915(i) re: population eligibility) #youth Up to 370 at any time 200 first year; ultimately Populations Served Functions and Responsibilities MD CARES & Rural CARES (SOC Grants) Stability Initiative SAFETY Initiative 1915(i) State Plan Amendment Targeted Case Management, Tier 3 Intensive Care Coordination using a Wraparound service delivery model Child and Family Team Facilitation Utilize assessment tools (e.g., Child and Adolescent Needs and Strengths) Connections and referrals to natural and professional supports, including peer support Management of the Plan of Care Utilization of management information system Continuous Quality Improvement, including participating in fidelity monitoring, satisfaction, and evaluation activities Provider network recruitment and management (CME only) The Institute for Innovation & Implementation 68 State Examples BREAK Care Coordinator Requirements, Certification, Training, Rates, Case Ratios, Supervisory Structure Peer Partner Requirements Certification Training Rates Case Ratios Supervisory Structure Interface between Care Coordinators and Peer Partners CARE COORDINATORS PEER PARTNERS 71 12

13 Wraparound Agencies in Louisiana Wraparound Facilitators (Care Coordinators) Engage family and team members Facilitate Child and Family Team (CFT) Monitor plan implementation Prepare for transition Document outcome data Collaborate with Peer Partners Paid PMPM ($1035) Case ratio: 1 to 10 Supervisory structure: 1 supervisor to 8 facilitators Wraparound Agencies in Louisiana Training Current contract with University of Maryland Development of core competencies through prescribed training program for Facilitators and Supervisors Creation of in state trainers/coaches for sustainability Louisiana Department of Health and Hospitals Office of Behavioral Health 73 Louisiana Department of Health and Hospitals Office of Behavioral Health 74 Peer Partners in Louisiana Peer Partners in Louisiana Parent/Youth Support Specialists Engage parent and youth Provide education/support in wraparound process Provide education on behavioral health issues and services Offer skill building in areas of need identified by CFT Collaborate with Wraparound Facilitators Paid Fee for Service ($40/hour, rate change pending) Case ratio: 1 to 20 Supervisory structure: 1 supervisor to 4 PSS/YSS Training University of Maryland WAA training University of Maryland Parent Partner training Functional Behavioral Approach training Content specific training Use of self in relationship (boundaries) Ethics Confidentiality Other Louisiana Department of Health and Hospitals Office of Behavioral Health 75 Louisiana Department of Health and Hospitals Office of Behavioral Health 76 Care Management Care Managers are have a BA/BS or masters degree in social service. The CMO s have established a certification process and different levels of certification. Care Managers are required to attend a series of trainings provided by CSOC. Family Support Partners are certified through Rutgers UBHC. CSOC training partner. Care Managers are trained by Family Support Organizations

14 Care Management Care management is provided for youth with both high and moderate needs NJ is moving toward a caseload size of 14 with a mixed caseload of high and moderate (currently in transition) Care Managers are supervised by a master s prepared supervisor Supervisors have 6 Care Managers on their team Behavioral Health Home NJ is currently working on a pilot BHH. The goal of the BHH is to expand the Child Family Team. We are looking to add a nurse and wellness coach to all teams for youth identified with a chronic condition Contract Requirements Caseloads of 10 Child and Family Teams Strengths Needs and Culture Discovery Wraparound Care Plan Ohio Scales Staff attends all training and coaching required Billing Wraparound Wraparound teams bill fee for service through the integrated MMIS system. Request prior authorization: For Medicaid as payor source; and For ODMHSAS state funding as payor source. CC is the highest level of targeted case management. Must submit letters of collaboration with all other providers billing MMIS system

15 Intensive Care Coordination: Massachusetts 1:10 average care coordinator to youth/family ratio Average length of enrollment for youth who graduate from ICC is months CANS is used as part of a comprehensive psychosocial assessment for ICC 1:8 average ICC supervisor to care coordinator ratio Care Coordinators: Intensive Care Coordination: Massachusetts CANS certified Skill and competency based training in the delivery of ICC consistent with Systems of Care philosophy and the wraparound planning process and have experience working with youth with SED and their families Weekly individual supervision with a behavioral health clinician licensed at the independent practice level, Weekly individual, group, or dyad supervision with the senior care coordinator. Master s degree in a mental health field; or bachelor s degree in a human services field and one year of relevant experience working with families or youth. If the bachelor s degree is not in a human services field, additional life or work experience may be considered in place of the human services degree. Individuals with an associate s degree or high school diploma must have a minimum of five years of experience working with the target population; experience in navigating any of the child/family serving systems; and experience advocating for family members who are involved with behavioral health systems Intensive Care Coordination: Massachusetts T1017 HN Targeted Case Management, per 15 minutes (service provided by a Bachelor level care manager) : $18.88 August 1, 2013 July 31, 2014 $19.07 August 1, 2014, and after T1017 HO Targeted Case Management, per 15 minutes (service provided by a Master level care manager): $23.74 August 1, 2013 July 31, 2014 $23.98 August 1, 2014, and after Family Support & Training (Family Partners): Massachusetts A Family Partner must have Experience as a caregiver of youth with special needs, preferably youth with mental health needs Experience in navigating any of the youth and family serving systems Either a bachelor's degree in a human services field from an accredited academic institution, or an associate s degree in a human services field from an accredited academic institution and one year of experience working with children, adolescents, or transition age youth and families, or a high school diploma or equivalent and a minimum of two years of experience working with children, adolescents, or transition age youth and families. If the bachelor's or associate s degree is not in a human services field, additional life or work experience may be considered in place of the human services degree. H0038 $15.60 per 15 minutes Payment & Financing for All Remedy Services No data to build case rate Rate setting agency developed 15 minute unit costs for each service Managed care entities (MCEs) paid through addition to capitation rate, based on unit rates and assumed utilization MCEs not at risk for Remedy services initially performed an annual reconciliation Massachusetts Executive Office of Health and Human Services

16 Training & Technical Assistance The Institute for Innovation & Implementation at the University of Maryland School of Social Work provides training, coaching, policy and finance support, fidelity and outcomes monitoring, and evaluation to support the CME and CCOs in Maryland. The Institute is a founding member of the National Wraparound Implementation Center (NWIC). Wraparound Practitioner Certification: Online trainings In person training On Site Coaching Team Observations Document Review Ongoing Certification (For more information on the Wraparound Practitioner Certificate Program at the UM SSW, please contact Marlene Matarese at mmatarese@ssw.umaryland.edu) Staffing Requirements CMEs in MD must employ: Executive Director Chief of Finance Provider Network Director Clinical Director Care Coordinator Supervisors Care Coordinators Community Resource Specialists Quality Assurance and Data Director CCOs have few required personnel (care coordinators, care coordinator supervisors, clinical director) in the proposed SPA; more delineation will occur in the individual RFPs. The Institute for Innovation & Implementation 91 The Institute for Innovation & Implementation 92 Care Coordinator Requirements Care Coordinators in MD must: Have a minimum of a bachelor s Degree and be enrolled in or have completed the Wraparound Practitioner Certificate Program OR Have a minimum of a high school diploma or equivalency, Be at least 21 years old Have been a participant of or are/were the direct caregiver of an individual who received services from the public mental health system Have completed the Family Support Partner Certificate Program and are enrolled in or have completed the Wraparound Practitioner Certificate Program Case and Supervisor Ratios Staff family Ratio CME: 1:9 to 1:11 CCO: 1:8 Supervisor care coordinator ratio (supervisors do not maintain a caseload) CME: 1:6 to 1:8 CCO: 1:7 The Institute for Innovation & Implementation 93 The Institute for Innovation & Implementation 94 Care Coordinator Supervisor Requirements Care Coordinator Supervisors in MD must: Have a Master s Degree in a human services field and two years of experience in a human services position Have at least one year experience working in community based service provision Have at least one year experience working with children, youth and families Possess an understanding of child and adolescent development Have completed trainings on Wraparound, crisis planning, system of care, and comprehensive screening and assessment tools Be enrolled in or have completed the Wraparound Practitioner certificate program or other equivalent training and certification Billing Rates CME: The state funded rate as of July 1, 2014 will be a full year equivalent of $14, annual per child (approximately $ per child per month). This rate is inclusive of CC costs and CME operating expenses for the first year of the CME contract CCO: Under the pending TCM SPA, billing units will be in 15 minute increments. Proposed rate in 1915(i) SPA (version released for public comment, fall 2013): $24.06/15 minutes or $294.24/week (up to $15,003/year) Proposed reduced rate while child is in a residential placement up to a certain length of stay (40% of regular rate) The Institute for Innovation & Implementation 95 The Institute for Innovation & Implementation 96 16

17 Provision of Family Peer Support Family peer support is available to families enrolled in care coordination. Family peer support specialists are employed through family support organizations. Family Support Specialists must meet the following requirements: Be at least 21 years old Receive supervision form an individual who is at least 21 years old and has at least 3 years of experiencing providing peer support Have current or prior experience as a caregiver of a child with a SED or young adult with SMI Be enrolled in the Wraparound Practitioner Certificate Program for Family Support Partners Under the 1915(i), family peer support will be reimbursed at $15.97 per 15 minute unit for face to face services or $7.98 per 15 minute unit for telephonic or non face to face activities Youth enrolled in the CME can access peer support through discretionary funds State Examples Access to Services and Supports Provider network Interface with MCOs/BHOs/ASO for Service Authorization Coordination with Primary Care, Courts, Schools The Institute for Innovation & Implementation SERVICES & SUPPORTS Services & Supports in Louisiana State Plan service array Inclusive of evidence based practices Community based alternatives Out of home placement options Specialized Services for youth in CSoC Parent Support & Training Youth Support & Training Crisis Stabilization Independent Living/Skills Building Short term Respite Natural supports Louisiana Department of Health and Hospitals Office of Behavioral Health 101 Authorization Process in Louisiana Statewide Management Organization (SMO) receives and reviews plan of care created and authorized by the Child & Family Team (CFT). SMO approves authorization based on indications from CANS, Independent Behavioral Health Assessment and CFT recommendations. SMO builds and monitors authorization to ensure youth receive appropriate level, frequency and duration of care. 102 Louisiana Department of Health and Hospitals Office of Behavioral Health 17

18 Coordination in Louisiana State level Entire managed behavioral healthcare system is partnership of: Office of Behavioral Health Medicaid Department of Children and Family Services Department of Education Office of Juvenile Justice Established Governance Board through Executive Order Meetings: Judges, provider associations, etc. Coordination in Louisiana Regional level Community Teams Child and Family Teams Relationships Judges Schools Informal/Natural supports 103 Louisiana Department of Health and Hospitals Office of Behavioral Health 104 Louisiana Department of Health and Hospitals Office of Behavioral Health Outpatient Services Referral to Perform Care is not required for outpatient services, such outpatient counseling, psychiatric evaluations / medication monitoring, anger management, etc. NJ MentalHealthCares maintains a thorough directory of services and can be accessed by visiting njmentalhealthcares.org or calling HELP Intensive In-Community Services Our in-community services are flexible therapy services that are provided at the home or other incommunity sites. What are IIC and BA Services? Focuses on (re)engaging the family into community based services (must have CMO or MRSS involvement) IIC Intensive In-Community Services Psychotherapy services provided in the youth s home. Securing appointments Address symptom reduction Preparing for appointments Time limited Processing through transition Focused on skill strengthening BA Behavioral Assistance Under a plan developed by an IIC therapist, the BA will work to modify specific behaviors of the youth. Provided based on an evaluation of need Part of a comprehensive plan of care Provided in the community

19 In Home Therapy delivered in the home only for the convenience of the family A way to get supervision for the youth / young adult to get him/her out of the house A substitute for individual and/or family therapy IIC is Not: BA is Not: A long term service A long term service Mentoring Out of Home Intensity of Service* Psych Community Homes (PCH) Specialty Beds (SPEC) Residential Treatment Centers (RTC) Group Homes (GH) Treatment Homes (TH) * Intensity of Service (IOS): Levels of OOH treatment based on intensity, frequency, and duration of treatment CSOC SUBSTANCE ABUSE TREATMENT SERVICES Available Services: Assessment (SA Evaluation, Needs Bio Psychosocial BPS) *Outpatient (OP) *Intensive Outpatient (IOP) *Partial Care (PC) *Long Term Residential (LT RTC) *Short Term Residential (ST RTC) Detoxification All service authorizations are based on clinical justification. *Qualifies for enhancement services for co occurring youth Access to Community Services In 2000, NJ Served Approximately 7000 Children In Community based Care Management, In Home and day treatment programs In 2013, NJ Served over 44,000 In Care Management, In Community and day treatment programs( +500%) In 2003, 40% of newly enrolled children were under 14 years old, in 2013 that percentage had grown to 65% Tends to indicate system of care has become more preventative, families are seeking services sooner Schools IDEA Transitions Education OJA Community Safety placement Community Support Housing Transportation Food Specialty BH Services Linkage Assessment CHILDREN S HEALTH HOME Linkage Child & Family SOC Team Engagement Advocacy Wraparound Supports Psychiatrist Medication Management Therapy Family Support Wellness Services & Services Team Approach One Care Plan Team Approach One Care Plan Support OKDHS Safety Placement(s) Permanency I N T E G R A T I O N Specialty Healthcare PCMH Access to physician Consultation with HH EPSDT screening Immunization Referral to specialty care Transition to/from hospital care

20 Massachusetts CBHI/Remedy Services Intensive Care Coordination (Wraparound) Family Support & Training (Family Partners) In Home Therapy In Home Behavioral Services Therapeutic Mentoring Mobile Crisis Intervention Crisis Stabilization * 115 Massachusetts Executive Office of Health and Human Services 116 Families decide on most appropriate initial service Emergency Services Mobile Crisis Intervention Access to Care Coordination Intensive Care Coordination (Wraparound) Clinical Assessment inc. CANS SED determination for eligibility Medical Necessity determination Care coordination In-Home Therapy Clinical Assessment inc. CANS Medical necessity determination Care coordination available Outpatient Therapy Clinical Assessment inc. CANS Medical necessity determination Care coordination available Additional Services (accessed through core clinical services) In-Home Behavioral Services Family Partners Therapeutic Mentoring Massachusetts Executive Office of Health and Human Services 117 MCO MCO MCO MCO Massachusetts 1115 Waiver, State Plan (TCM) State Medicaid Agency (MassHealth) Purchaser BHO Standardized tools for screening and assessment by PCPs CANS *Locally Based Care Management Entities Non Profit BH and Specialty Providers (called Community Services Agencies) Ensure Child & Family Team Plan of Care Provide Intensive Care Coordination Provide peer supports and link to natural helpers Manage utilization, quality and outcomes at service level MCO PCCM 118 Managed Care Entity Authorization Parameters for Services INITIAL AUTHORIZATION PERIOD FOR ICC AND FS&T : Intensive Care Coordination (ICC) 1 unit = 15 minutes Family Support and Training (FS&T) 1 unit = 15 minutes 192 total units for ICC and FS&T combined, with no maximum units for either CBHI Coordination and Governance EOHHS Secretary (17 Agencies) CBHI Staff (4.5 FTE) EVERY 90 DAYS FOLLOWING INITIAL AUTHORIZATION: CBHI Executive Committee Office of Medicaid Intensive Care Coordination (ICC) 208 units/90 days (13 weeks) 1 unit = 15 minutes Family Support and Training (FS&T) 208 units/90 days (13 weeks) 1 unit = 15 minutes* Children s BH Advisory Council Office of Behavioral Health (9 FTE) Note: All authorization parameters are floors not ceilings. If a provider uses up the units authorized in a given time parameter prior to the end of the end date of the authorization, the provider can contact the MCE to request additional units. Dayana Simons, Center for Health Care Strategies, Interagency Implementation Team MassHealth Implementation Team MCE Workgroup Massachusetts Executive Office of Health and Human Services

21 Maryland s Public Behavioral Health System Maryland has an 1115 Waiver, which creates the following structures for Medicaid service delivery: HealthChoice MCOs for somatic health and dental Behavioral Health Carve Out Fee For Service Administrative Service Organization (ASO) ValueOptions (new contract to be awarded in early 2015) Medicaid eligible youth can access the fee for service PBHS and 1915(i) eligible use will be able to access specialty services through the SPA Discretionary Funds (CME Only) General funds allocated per youth per day to support components of the Plan of Care not otherwise funded. (All State only or grant funds) Residential Services Medicaid funds inpatient or RTC stays (Medical Necessity) Custodial agency funds group home or foster care placement, with some Medicaid reimbursement through the Rehab Option Behavioral Health Homes Designed around the population of adults with SPMI, although youth with SED can be served 121 The Institute for Innovation & Implementation 122 Role of the ASO Manage the Behavioral Health Carve Out, which will include CCOs and providers of 1915(i) services Deliverables related to the 1915(i) (per RFP) include: Designate a staff member to be the liaison with responsibility for oversight and problem resolution and to interface with CCOs Register providers of specialized services Review and authorize requests for specialized services Jointly determine with local mental health authorities medical eligibility for admission using needs based eligibility criteria Assure that POCs for each participant reflect all behavioral health services authorized and develop a mechanism to assure that participants are actively engaged in behavioral health treatment Conduct on site audits of providers Simplified Version of Maryland s Public Behavioral Health System Service Array for Youth Maryland has a traditional but robust PBHS for children and youth with Medicaid and MCHP Other services and supports outside the Public Behavioral Health System include Multi Systemic Therapy, Functional Family Therapy, Parent Child Interaction Therapy, Treatment Foster Care, Peer Support, and Community Based and Natural Supports. Eligibility will depend on the funder and associated parameters for each individual service. The Institute for Innovation & Implementation 123 The Institute for Innovation & Implementation 124 Proposed Services under the 1915(i) Maryland has a robust public mental health system; these services will fill gaps in the current home and community based provider array: Care Coordination (provided by CCO who is a TCM Provider) Community Based Respite Care Out of Home Respite Family Peer Support Mobile Crisis Response and Stabilization Intensive In Home Services (differentiated from Therapeutic Behavioral Services and from Psychiatric Rehabilitation Programs) Expressive & Experiential Behavioral Services (art, dance, drama, music, equine, horticultural) Customized Goods and Services Eligibility and Authorization Process for Care Coordination Services For populations served by the CME, eligibility screenings are performed by referral sources (DJS, DHR, CSA, LCT, LMB, public local school systems) After the referral source gatekeeper has determined that a youth is eligible and has referred the youth to the CME, the CME's Clinical Director reviews the referral and authorizes enrollment. For the 1915(i) SPA, eligibility screenings are performed by the CCO based on Certificate of Need (CON) documents (psychiatric/psychosocial assessments). The clinical information will be compared to the MD Medicaid medical necessity criteria (MNC) for this level of care. the ASO, in a team decision process with the CSA, will review the CON documents and complete a CASII assessment. When the CON is determined to meet the MNC, the ASO authorizes all of the medically appropriate behavioral health services. The Institute for Innovation & Implementation 125 The Institute for Innovation & Implementation

22 Interagency Coordination At the state level, the Children s Cabinet (which funds the CME) is chaired by the Executive Director of GOC and comprised of the Secretaries of the Departments of Budget and Management, Disabilities, Health and Mental Hygiene, Human Resource (child welfare), Juvenile Services, and the Superintendent of the Maryland State Department of Education At the practice level, the CME s program plan must: Describe how it will develop or improve upon positive relationships the lead agencies (e.g., DSS, DJS) Describe how it will enhance their current relationships with the direct services provider community to facilitate appropriate linkages and services to families CCOs and CMEs are required to commit to coordination with all agencies involved in the participant s POC and work with the State and local childand family serving agencies to develop a network of clinical and natural supports in the community to address strengths and needs identified in each POC State Examples Evaluation, Quality Monitoring and Outcomes The Institute for Innovation & Implementation EVALUATION QUALITY MONITORING OUTCOMES Quality Monitoring/Evaluation in Louisiana National Wraparound Initiative Tools Wraparound Fidelity Index (WFI EZ): Office of Behavioral Health is currently conducting the WFI EZ with all five Wraparound Agencies Document Review Measure (DRM): SMO will use the DRM to compliment the WFI EZ with all five Wraparound Agencies Planned evaluation activities with University of Washington Wraparound Evaluation & Research Team Tracking Outcomes in Louisiana Child and Adolescent Needs and Strengths Assessment (CANS) scores Out of Home placements Psychiatric Emergency Department utilization Inpatient Psychiatric utilization Home and Community Based Service utilization School suspensions and expulsions Costs Louisiana Department of Health and Hospitals Office of Behavioral Health 131 Louisiana Department of Health and Hospitals Office of Behavioral Health

23 CANS Scores Out of Home Placements (3/1/12 to 3/31/14) c CSoC Percent of CSoC children and youth who had restrictive placements prior to enrollment in WAA: 31.4% d TGH 3 Nursing Facility 4 PRTF Inpatient Psyc Percent of CSoC children and youth place in restrictive placement after enrolling in WAA = 18.3% Initial 180 Days 360 Days 540 Days CSoC Children Inpatient Psychiatric Utilization Home and Community Based Service Utilization Admits / Days / Total Admissions for all CSoC Inpatient Stays in Month / Number of CSoC Participants in Month * Average Length of Stay (Total Days for all CSoC Inpatient Stays Discharged in Month) / (Number of CSoC Participants in Month) * Services Utilized Total Days for all CSoC Inpatient Stays in Month / Total Admissions for all CSoC Inpatient Stays in Month School Performance/Conduct (Suspensions and Expulsions) School Performance Measures CSoC Expenditures 30% 25% $12,000,000 Waiver Services and WAA Payments $10,933,421 20% $10,000,000 15% % Members with Missed Days % Members with Suspensions % Members with Expulsions $8,000,000 $6,000,000 $5,940,505 Contract Yr 1 Contract Yr 2 10% $4,000,000 5% 0% Period 1 Period 2 Period 3 Period 4 *based on quarterly data reported by CSoC Wraparound agencies $2,000,000 $0 $1,143,567 $378,451 Waiver Services WAA Payments 137 Louisiana Department of Health and Hospitals Office of Behavioral Health

24 CSoC Expenditures $6,000,000 $5,000,000 State Plan Services for CSoC Enrollees $5,522,977 $4,000,000 $3,000,000 $2,000,000 $1,000,000 $930,454 $2,173,438 $1,784,486 Contract Yr 1 Contract Yr 2 $0 Inpatient Outpatient Louisiana Department of Health and Hospitals Office of Behavioral Health What Have We Learned? The system of care model works Less children in institutional care Less children accessing inpatient treatment Closure of state child psychiatric hospital and RTCs Very few children in out of state facilities Children in out of home care have more intense needs than prior to the system of care development Wraparound works Less youth in detention centers many reasons, not necessarily because of the system of care Federal funding support under Title XIX Evaluation Quality Monitoring All providers certified on CANS Tool Certification for BA and FSO Credentialing for IIC/IIH Utilization Management by CSA Contracting monitoring by CSOC Child Family Teams WFI is used by CMO s Management by data NJ Department of Children and Families Fiscal Year 2014 $1.65 Billion Overall Department Budget NJ Department of Children and Families Fiscal Year 2014 $498 Million Children s System of Care Funds by State/Federal/Dedicated Funds by Division Funds by State/Federal Funds by Service

25 A Continuum of Care: Mobile Response Working hard to keep children & youth successfully at home & avoid hospitalization or placement. A Continuum of Care: Mobile Response NJ DCF CHILDREN'S SYSTEM OF CARE (CSOC) Mobile Response Children Stabilized in Current Living Situation 4/1/2014 4/30/2014 ( n = 1,532 ) Did not stay in current living situation 4% ,443 1,760 1,610 MRSS Service Dispatch Data 2011 April ,498 1, , ,296 1,055 1,095 1, Stayed in Current Living Situation 96% Jan Feb Mar April May June July Aug Sept Oct Nov Dec Out of Home Treatment Authorizations (which provide access to out of home care) is reduced due to more access and availability of community resources NJ DCF CHILDREN'S SYSTEM OF CARE (CSOC) Authorized Out-of-State Placements Number of youth in Out-of-State placements at the first of the month In April % (157) of youth in Out of State programs were involved with child welfare system further complicating opportunities for family engagement Today There are 3 youth in Out of State behavioral health treatment programs, youth is involved with child welfare Mar Apr Jan Jan Jan Jan Jan Jan Jan A Continuum of Care: Care Management Organization (CMO) Serving over 10,000 children, with a focus on the high need youth and their families A Continuum of Care: Out of Home Treatment Currently, most youth receiving out of home treatment are adolescents Gender # Pct Female % Male % Total %

26 E Team OU Measurement (E TEAM) Department of the University of Oklahoma. The E TEAM is a full service social research department with senior researchers, data analysts, technical writers, data base developers and managers, and a pool of research assistants representing decades of experience in all phases of research data processing and analysis. Belinda Biscoe Boni, Ph.D., Associate Vice President, Public and Community Services, at the University of Oklahoma, College of Continuing Education, is the Director of E TEAM Youth Information System (YIS) YIS provides a wide range of reports for use by managers, site personnel and community stakeholders also provides a wide range of reports for use by managers, site personnel and community stakeholders. YIS tracks the following: Process monitoring: Referrals, enrollments, discharges Flex fund expenditures Wraparound implementation Outcomes measures: periodic (6 month) assessments. Outcomes After Six months, SFY2013 (n=836) Reduced Days of Out of Home Placement 49% Reduced School Detentions 51% Reduced Number of Youths Self Harming 42% Reduced Arrests 66% Reduced Contacts with Law Enforcement 51% Reduced Days Absent from School 46% Reduced Days Suspended from School Massachusetts Quality/Fidelity Monitoring Wraparound Fidelity Assessment System MA WFAS (NWI) Wraparound Fidelity Index (WFI 4) initially Wraparound Fidelity Index Parent/Caregiver Treatment Observation Measure (TOM) Document Review Measure (DRM) initially MCE Medical Record Review (standardized tool) System of Care Practice Review SOCPR (USF) Dayana Simons, Center for Health Care Strategies, Louisiana Department of Health and Hospitals Office of Behavioral

27 Massachusetts Outcomes Tracked Massachusetts Outcomes: Reduced Use of Inpatient Care Multiple process variables including: Utilization of: Mobile Crisis Intervention Inpatient Psychiatric Home and Community Based Services Out of Home placements Costs Penetration 0.40% 0.35% 0.30% 0.25% 0.20% 0.15% 0.10% 0.05% Penetration Rate and Bed Days per 1000 Members Under 19 of Psychiatric Inpatient Services (Based on MBHP Claims thru 1/13/12) % 2009 Q Q Q Q Q Q Q Q Q Q Q Q Q 1 0 Dayana Simons, Center for Health Care Strategies, Penetration 0.30% 0.32% 0.32% 0.27% 0.21% 0.25% 0.27% 0.27% 0.21% 0.27% 0.25% 0.28% 0.21% Units/ Quarter Massachusetts Executive Office of Health and Human Services 158 Outcomes & Evaluation Fidelity and quality of the CME is monitored by The Institute at UM SSW under contract with GOC The Institute utilizes the WFI EZ, COMET, TOMS, IOTTA, California Health Kids Survey Resilience & Youth Development Module, and Family Empowerment Scale data from the families being served to monitor and measure ICC/Wraparound quality and fidelity. Use of TMS WrapLogic will support the fidelity monitoring and the additional data collection Resiliency measures are incorporated into the WFI process as part of CHIRPA Outcomes related to clinical and functional status and cost are being assessed, both independently and through the use of an administrative comparison group 159 The Institute for Innovation & Implementation 160 Reasons for Discharge from the CME: July to December, 2013 Semi Annual Trend in Successful Completions: July, 2012 to December, 2013 Source: The Institute for Innovation and Implementation (2014). Care Management Entities: Maryland Implementation Report: FY14 QTR 1 & 2. Baltimore, MD. Source: The Institute for Innovation and Implementation (2014). Care Management Entities: Maryland Implementation Report: FY14 QTR 1 & 2. Baltimore, MD. The Institute for Innovation & Implementation 161 The Institute for Innovation & Implementation

28 TH6 Wraparound Fidelity Index Short Term (WFI EZ) Additional CME Outcomes 75% of youth discharged to a stable, non restrictive living situation (parent or relative s home, regular foster home, adoptive home, or living independently) during the first and second quarters of FY14. This is an increase from the previous reporting period (68%) and the first and second quarters of FY13 (63%). The number of CANS Needs items on which youth demonstrated need for intervention (score of 2 or 3) at discharge has remained consistently low, with an average of 5.5 (sd=5.70) out of 41 items during the first and second quarters of FY14 These continued improvements in youth outcomes may reflect Maryland Choices, LLC adapting to the demands of serving as Maryland s single Statewide CME provider and working on ways to improve its implementation of the Wraparound model over the past 18 months. Source: The Institute for Innovation and Implementation (2014). Care Management Entities: Maryland Implementation Report: FY14 QTR 1 & 2. Baltimore, MD. Source: The Institute for Innovation and Implementation (2014). Care Management Entities: Maryland Implementation Report: FY14 QTR 1 & 2. Baltimore, MD. The Institute for Innovation & Implementation 163 The Institute for Innovation & Implementation 164 Costs of Care: Results from MD s PRTF Demonstration Youth enrolled in the PRTF Demonstration Grant and served by the CME had an average per member, per year cost of care of $32,987 (Medicaid costs only; n=174) Youth enrolled in a PRTF during the same time (not served by the CME) had an average per member, per year cost of care of $153,417 (Medicaid costs only; n=1,119) These costs include the capitated MCO rate, medications, inpatient hospitalizations, oral health care, home health services and all services covered by Medicaid. Time Period: September 30, 2009 June 30, 2011 (claims paid through 10/31/11) Source: Medicaid claims data provided by The Hilltop Institute to the University of Maryland under the CHIPRA Quality Demonstration Grant (November 2011) Federal Medicaid Guidance 7/11/13 State Medicaid Director s Tri Agency Letter on Trauma Informed Treatment Policy Guidance/Downloads/SMD pdf 5/7/13 Informational Bulletin on Coverage of Behavioral Health Services for Children, Youth and Young Adults with Significant Mental Health Conditions policy guidance/downloads/cib pdf 3/27/13 Informational Bulletin on Prevention and Early Identification of Mental Health and Substance use Conditions policy guidance/downloads/cib pdf 8/24/12 Informational Bulletin on Resources Strengthening the Management of Psychotropic Medications for Vulnerable Populations Policy Guidance/Downloads/CIB pdf 11/21/11 State Medicaid Directors Tri Agency Letter on Appropriate Use of Psychotropic Medications Among Children in Foster Care policy guidance/downloads/smd pdf The Institute for Innovation & Implementation Resources For further information, contact: Faces of Medicaid: Examining Children s Behavioral Health Service Utilization and Expenditures Making Medicaid Work for Children in Child Welfare: Examples from the Field Customizing Health Homes for Children with Serious Behavioral Health Challenges _SPires.pdf Psychotropic Medications Quality Improvement Collaborative: Improving the Use of Psychotropic Medications Among Children in Foster Care url_nocat3961/info url_nocat_show.htm?doc_id= CHIPRA Care Management Entity Quality Collaborative url_nocat3961/info url_nocat_show.htm?doc_id= Return on Investment in Systems of Care for Children with Behavioral Health Challenges pdf Massachusetts CBHI website: Rosie D. v. Patrick (United States District Court, District of Massachusetts), Civil Action Number MAP National Wraparound Initiative website: Sheila A. Pires, Partner Human Service Collaborative sapires@aol.com Jody Levison Johnson Deputy Assistant Secretary Office of Behavioral Health Jody.Levison@la.gov Elizabeth Manley, Division Director CSOC Elizabeth.Manley@dcf.state.nj.us NJ Children s System of Care PerformCare Member Services: Jackie Shipp Director of Community Based Services ODMHSAS jshipp@odmhsas.org Dayana Simons, Senior Program Officer Center for Health Care Strategies, Inc. dsimons@chcs.org Michelle Zabel, Director The Institute for Innovation & Implementation Director, Technical Assistance Network mzabel@ssw.umaryland.edu Building Systems of Care: A Primer, 2 nd edition