An Overview and Analysis of the PRTF Waiver Demonstration: A National and Local Perspective

Transcription

1 An Overview and Analysis of the PRTF Waiver Demonstration: A National and Local Perspective 27th Annual Children s Mental Health Research and Policy Conference, Tampa, Florida March 2 5, 2014 Presenters Sherry Peters, MSW, ACSW Director Psychiatric Residential Treatment Waiver Initiative Georgetown Center for Child and Human Development, Georgetown University Lauren Rabinovitz, MPH, MSW, LCSW-C Georgetown Center for Child and Human Development, Georgetown University Anne Leopold, MS Disability Services Center, JBS International, Inc. Angela Blizzard, BA Division of Child and Adolescent Psychiatry, University of Maryland School of Medicine, Baltimore, MD Larraine Bernstein, MS Division of Child and Adolescent Psychiatry, University of Maryland School of Medicine, Baltimore, MD Amanda Mosby, MA Division of Child and Adolescent Psychiatry, University of Maryland School of Medicine, Baltimore, MD 1

2 Objectives Provide an overview of the alternatives to PRTF implemented in nine states. Assess the effectiveness of services, functional outcomes, implementation strategies, challenges, and strengths of the wraparound approach and services delivered in the Demonstration. Provide a comprehensive review of services provided by Maryland including characteristics of consumers served and service utilization trends. Overview of the PRTF Demonstration What is it? In 2005, Congress authorized a five-year Demonstration project to test whether children/youth who meet requirements to be served in a PRTF could successfully and cost effectively be served in the community. How did it work? The Centers for Medicare & Medicaid Services (CMS) selected 10 states to compare effective ways of providing home and community-based services (HCBS) as an alternative to care in PRTFs for children/youth with serious emotional disturbances (SED). 2

3 Overview of the PRTF Demonstration How was it financed? Participating states were permitted to use the 1915(c) waiver authority to deliver services. What did states do? States had the opportunity to develop unique, culturally relevant community-based services and care coordination. All states used the wraparound values in their care coordination approach. Participating PRTF Demonstration States 3

4 Core Services offered within a Wraparound Approach Care Coordination/ Wraparound Facilitation Customized Goods and Services Intensive in-home therapy and support Crisis Support Child, Youth and Family Peer to Peer Support (Parent and Youth) Respite Mentoring Outcomes from the Alternatives to Psychiatric Residential Treatment Facilities Demonstration: A National Perspective 4

5 Presenters Lauren Rabinovitz Georgetown Center for Child and Human Development, Georgetown University Anne Leopold Disability Services Center JBS International, Inc. Objectives Assess the effectiveness of services, functional outcomes, implementation strategies, challenges, and strengths of the wraparound approach and services delivered in the Demonstration. Quantitative and Qualitative Outcomes Discuss the benefits of the Demonstration, including the wraparound approach, and the need for making the waiver permanent. 5

6 National Evaluation By the end of 5th year, 9 participating states provided community-based alternatives to residential treatment to 5314 children/youth. Community-based services averaged 32% of the comparable services provided in PRTFs. On average the youth either maintained or improved their functional outcomes Care/Alternatives-to-Psychiatric-Residential-Treatment-Facilities-Demonstration-PRTF.html Secondary Data Analysis Mixed Methods Qualitative and Quantitative 6

7 Quantitative Data Analysis Claims data and outcome data for all implementation years Analyzed data using STATA Demographics Outcomes (functional assessment instruments - CANS, CAFAS, CBCL) at 6-months intervals Service Utilization Costs Sufficient samples sizes to detect significant differences in three states for the first 12 months Other states showed trends but not enough power to show significance Trends but not enough power to show significance beyond 12 months Demographics State 1 State 2 State 3 Age (mean) Gender (%) Male Female Race/Ethnicity (%) White African American American Indian Hispanic Diagnosis (%) Schizophrenia/Psychotic Mood/Anxiety Adjustment Attention/Disruptive Other Childhood

8 Demographics State 1 State 2 State 3 Current Living Arrangement (%) Family or relative s home Foster care home Therapeutic foster care Detention Other residential setting Age at first receipt of MHS (mean) Number of PRTF admissions to date (%) Effectiveness, Outcomes, and Strengths 8

9 Effectiveness, Outcomes, and Strengths Effectiveness, Outcomes, and Strengths 9

10 Cost 3/7/2014 Service Utilization Percentage of youth receiving this service 91% Wraparound Facilitation 19.6% Respite Care Hourly 33.3% Flex Funding 28% Consultative Clinical & Therapeutic Services 70.4% Habilitation Services Costs $250,000 Institutional Cost vs. PRTF Waiver Costs $200,000 $150,000 $100,000 Average Per Capita Institutional Costs Average Per Capita Waiver Costs $50,000 $0 AK GA IN KS MD MS MT SC VA States 10

11 Qualitative Data Analysis Interviews with 134 youth, families, service providers, local administrators, and state representatives and policy makers involved in the Demonstration to obtain insights from the field. Qualitative Analysis Initial Coding of Transcripts Revision of Codes Inter-rater reliability Thematic Analysis 11

12 Coding Prefixes Challenges Concerns Evaluation Future Implementation Lessons Services Strengths Success Stories Number of Quotations All Interviewees Success Stories Strengths Services Lessons Implementation Future Evaluation Concerns Challenges

13 Coding Families States Alaska Georgia Indiana Kansas Maryland Mississippi Montana South Carolina Virginia Role Admin-Macro Admin-Local Fam. Advocate Family Member Youth Provider Year Began Waiver Late 2007 Early 2008 Late 2008 Early 2009 Late 2009 Quotations Family Members - Strengths 13

14 Quotations Family Advocates - Strengths Quotations Providers - Services 14

15 Quotations Local Administrators - Implementation Quotations State Representative and Policymakers Challenges 15

16 Interview Clips [Add videos here] Looking Forward Why was the Waiver so successful? Services in home Family involvement Satisfaction Service Expansion Cost savings Advocating for the permanence of the Waiver 16

17 Georgetown Contact Information Sherry Peters, MSW, ACSW Director of PRTF Waiver Initiative National Technical Assistance Center for Children's Mental Health Georgetown University Center for Child and Human Development Phone: (202) Fax: (202) Website: JBS International Contact Information Eileen Elias, M.Ed. Senior Policy Advisor for Disability and Mental Health JBS International, Inc Security Lane, Suite 800 North Bethesda, MD Phone: Fax: website: 17

18 Resources National Evaluation - Report Care/Alternatives-to-Psychiatric-Residential-Treatment-Facilities-Demonstration-PRTF.html Report to the President and Congress Care/Downloads/PRTF-Demo-Report-.pdf CMCS and SAMHSA Informational Bulletin Adherence to the Wraparound Model in Maryland s Demonstration Waiver Angela Blizzard Larraine Bernstein This project is sponsored by the Department of Health and Mental Hygiene, the Mental Hygiene Administration via the 1915(c) Home and Community-Based Waiver Program Management, Workforce Development and Evaluation (OPASS# G/M00B ). 18

19 Acknowledgments Sharon Stephan Steve Pitts Deborah Medoff Eric Slade Michael Tager Maryland Mental Hygiene Administration Overview To provide an overview of the implementation of the Demonstration Waiver in Maryland To examine overall adherence to the Wraparound model in Maryland s Demonstration To examine adherence to the 10 Wraparound principles in Maryland s Demonstration 19

20 Implementation of Demonstration Waiver in Maryland Enrolled youth from October 2009 to September 2012 Served 273 youth 34 youth presently enrolled Administered by care management entities (CMEs) 2 CMEs initially coordinated care for youth enrolled in the Waiver Presently only 1 CME Implementation of Demonstration Waiver in Maryland Successes Availability of new Medicaidreimbursable services Individualized care-coordination 20

21 Implementation of Demonstration Waiver in Maryland Challenges New program to community providers Adhering to federal Medicaid compliance regulations Youth entering entered a RTC during Waiver enrollment 25% WFAS Evaluation Interviews conducted with families enrolled in Demonstration Waiver, as well as other funding streams served by CMEs Interviewed several times over course of service Interviews began 6 months after beginning services Interviews conducted for 133 youth enrolled in Waiver For all youth served by CMEs, 1160 interviews conducted 476 caregiver interviews 217 youth interviews 467 team member interviews 21

22 WFAS Evaluation Wraparound Fidelity Index Version 4.0 (WFI-4) Assesses adherence Wraparound model and 10 core elements of Wraparound Below Above 85 Not Borderline Adequate High Fidelity Wraparound Fidelity Fidelity Overall adherence: Caregiver (76%), team member (78%), youth (78%) Adherence - CME 22

23 Adherence Demonstration Waiver Strengths and Areas for Improvement Strengths Culturally competent Collaborative Voice and choice Areas for improvement Community based Outcome based 23

24 Implications Continued emphasis on incorporating family voice and cultural competence in Plans of Care Adequate implementation supports and policy changes needed to provide appropriate and sufficient community based services Continued research needed to explore relationship between high fidelity wraparound and youth outcomes (Effland, V., Walton, B., &McIntyre, J., 2011; Bruns et al., 2005) Characteristics of Youth and Caregivers and Service Utilization Trends in Maryland s Waiver Amanda Mosby Angela Blizzard Michael Tager Larraine Bernstein This project is sponsored by the Department of Health and Mental Hygiene, the Mental Hygiene Administration via the 1915(c) Home and Community-Based Waiver Program Management, Workforce Development and Evaluation (OPASS# G/M00B ). 24

25 Overview To provide an overview of the services offered in the Demonstration Waiver in Maryland. To determine the services most frequently used by youth enrolled in the Waiver. To examine characteristics of youth and their caregivers enrolled in the Waiver, and present preliminary youth and caregiver outcomes. Waiver Services in Maryland Caregiver Peer to Peer support Youth Peer to Peer support Family and youth training In-Home Respite Out-of- Home Respite Crisis and stabilization Expressive and experiential therapies 25

26 Waiver Services in Maryland Service Type Number of Organizations/ Providers Enrolled Expressive & Experiential 17 Crisis & Stabilization 7 Respite (in-home and out-of-home) 7 Caregiver Peer-to-Peer 2 Youth Peer-to-Peer 2 Family & Youth Training 2 Most Frequently Used Services Caregiver Peer-to-Peer 54% Crisis & Stabilization 30% Expressive & Experiential 28% Music 16% Equine 5% Art 5% Dance 2% Horticulture 0% Respite 23% Youth Peer-to-Peer 2% Family & Youth Training <1% 26

27 Youth Characteristics Average age of youth at enrollment Gender Male 59% Female 41% Racial/Ethnic group African American 54% Caucasian 36% Hispanic/Latino 1% Other 9% Region Baltimore City 38% Central 29% Eastern Shore 25% Western 4% Southern 4% 14.5 min=6.1, max=20.3 Care Management Entity Implementation Summary Report Dec 2009 through June 2012 Number of Prior Residential Treatment Center Admissions Number of Prior Admissions 0 Admissions 45% 1 Admission 29% 2 Admissions 10% 3 Admissions 7% 4 Admissions 3% 5+ Admissions 6% 27

28 Child & Adolescent Needs & Strengths (CANS) Scores Child Behavioral/Emotional Needs Child Risk Behaviors Impulse/Hyperactivity 63% Judgment 35% Anger Control 56% Social Behavior 27% Oppositional 51% Danger to others 15% Anxiety 47% Suicide Risk 9% Depression 35% Other self-harm 8% Conduct 31% Runaway 7% Adjustment to trauma 27% Self-mutilation 5% Psychosis 12% Sexual aggression 4% Substance use 2% Delinquency 4% Fire-setting 2% Child & Adolescent Needs & Strengths (CANS) Scores Child and Environmental Strengths Educational Environment 71% Relationship Permanency 70% Talents/Interests 66% Family 50% Optimism 46% Community Life 43% Spiritual/Religious 39% Interpersonal 37% Vocational 35% 28

29 Relationship of Caregivers to Youth Relationship to Youth Biological parent 50% Adoptive parent 10% Other 10% Foster parent 8% Grandparent 4% Live-in Friend/Relative 2% Step parent 0% Information missing 16% Caregiver Strengths & Needs Scores Caregiver Needs Physical 11% Mental health 10% Safety 4% Developmental 3% Caregiver Strengths Involvement 90% Organization 88% Residential Stability 85% Knowledge 82% Supervision 79% Social Resources 65% 29

30 Domain Preliminary Findings Child Needs and Risk Behaviors Baseline Mean Year 2 Mean F Df Sig. Depression/Anxiety Impulse/Hyperactivity ** Danger to Others Oppositional Behavior ** Psychosis Suicide Risk ** ** indicates p <.05 Social Behavior Preliminary Findings Child Strengths Domain BaselineMe Year 2 F Df Sig. an Mean Family Interpersonal ** Relationship Permanence ** ** indicates p <.05 30

31 Preliminary Findings Caregiver Strengths and Needs Domain Baseline Mean Year 2 Mean F Df Sig. Safety ** Involvement Knowledge Supervision ** indicates p <.05 Conclusion Initial findings demonstrating decreases in child needs and risk behaviors promising Are providers prepared to address youth and caregiver care needs? 31

32 Recommendations PRTF Waiver Demonstration Program evaluation is a critical component to assess the effectiveness and impact of local, state, and federal programs Consistent data collection procedures across sites Collection of complete data within sites Collaboration and partnerships are critical components for transforming systems and building capacities Need of policies to enable array of services and access to services that are Medicaid reimbursable 32