Intensive Treatment Foster Care, Intensive Services Foster Care and Therapeutic Foster Care ITFC, ISFC and TFC Differences in Policies and Practices (September 6, 2017, 4:00 5:30) Presenters Kathy Hughes President/Chief Executive Officer, ChildNet Youth and Family Services Camille Schraeder Executive Director, Redwood Community Services Jennie Sill County Children s Systems of Care (CSOC) Administrator Kern County Behavioral Health and Recovery Services Jackie Rutheiser Senior Policy Advocate, California Alliance of Child and Family Services Lynn Thull, Ph.D. Mental Health Policy and Practice Improvement Consultant, California Alliance of Child and Family Services 1
Agenda Overview of ITFC, ISFC and TFC Programs Target populations Funding sources Role and qualifications of the FFA, ITFC, ISFC and TFC parents Training requirements for parents Program requirements (MOU, respite, capacity) Social worker to client ratio ISFC Client Support Staff training and educational requirements Program rates and reimbursements Private pay clients In Lieu of and In Home Support Counselor Hours Mental Health Contract Requirements; Progress Notes; Medi-Cal National Provider Number ISFC and TFC Contracts and Programs Discussion Overview of the Programs FFAs: Created in 1986 to: recruit, screen, certify, train and provide professional support services to foster families to care for the more difficult nature of foster children being placed in foster care who are more emotionally disturbed, difficult to manage and without family support than ever before (later changed to also include who require that level of care as an alternative to a group home) ITFC: Created in 1990 and amended in 2008 to: enable foster children with severe emotional disturbance or who have serious behavioral problems and are at imminent risk or were in a psychiatric hospitalization or RCL 9 or higher level group home to be in a foster family home with highly trained and skilled foster parents to receive intensive services and supports (ISFC will replace ITFC on January 1, 2018) 2
Overview of the Programs ISFC: Created in 2017 (effective January 1, 2018) to: supersede ITFC to care for children and youth with intensive needs, including, but not limited to medical, therapeutic or behavioral needs. ISFC means a FFA model or a public delivery model of home-based family care for eligible children whose needs for safety, permanency, and well-being require specially trained resource parents and intensive professional and paraprofessional services and support in order to remain in a home-based setting, or to avoid or exit congregate care in a STRTP, group home or out-of-state residential center TFC: Created in 2017: as a result of the Katie A. v. Bonta lawsuit, TFC is intended for children and youth who require intensive and frequent mental health support in a family environment for short-term, intensive, highly coordinated, trauma-informed and individualized SMHS services activities provided by trained, intensely supervised, and supported TFC parents who are therapeutic change agents Organizations that Can Provide Programs FFA: Only California FFAs that are nationally accredited, or are in process of becoming nationally accredited by December 31, 2018, can approve FFA Resource Family homes ITFC: Ditto ISFC: Ditto with the addition that counties can operate a public delivery ISFC model by submitting to DSS a program description that complies with the ISFC statute without operating an FFA TFC: Only California FFAs that are nationally accredited are able to approve TFC parents to provide mental health services (note: it s not a placement ) 3
ISFC Target Populations (Including But Not Limited to This List) AWOL Aggressive and Assaultive Animal Cruelty Commercially Sexually Exploited Children (CSEC) Substance Use/Abuse Gang Activity Fire Setting Severe Mental Health Issues Suicidal Ideation Self Harm Psychiatric Hospitalization Violent Offenses Sex Offenders Property Damage Habitual Truancy Eating Disorder Three or More Placements Special Health Care Needs Medically Fragile TFC Target Populations TFC: Full scope Medi-Cal children and youth up to age 21 who have more complex emotional and mental health needs and therefore meet medical necessity criteria for Specialty Mental Health Services (SMHS) provided by Early and Periodic Screening, Diagnostic and Treatment (EPSDT) delivered through the TFC Model as a homebased alternative to high level care in institutional settings such as group homes and Short-term Residential Therapeutic Programs (STRTPs). Children and youth require intensive and frequent mental health support in a one-on-one family environment 4
TFC Target Populations (Must Have One of These Primary Diagnoses) Pervasive Developmental Disorders, except for Autistic Disorders Disruptive Behavior Disorders Attention Deficit Disorders Feeding and Eating Disorders of Infancy and Early Childhood Elimination Disorders Other Disorders of Infancy, Childhood, or Adolescence Schizophrenia and other Psychotic Disorders (except Psychotic Disorders due to General Medical Condition) TFC Target Populations (Must Have One of These Following Diagnosis) Mood Disorders, except Mood Disorders due to a General Medical Condition Anxiety Disorders, except Anxiety Disorders due to a General Medical Condition Somatoform Disorders Factitious Disorders Dissociative Disorders Paraphilias Gender Identity Disorders Eating Disorders Impulse Control Disorders Not Elsewhere Classified Adjustment Disorders Personality Disorders, excluding Antisocial Personality Disorder Medication-Induced Movement Disorders related to other included diagnoses. 5
Common Primary Mental Health Diagnoses for Youth Adjustment Disorder Post Traumatic Stress Disorder Depressive Disorders Anxiety Disorders Attention Deficit Disorders Conduct Disorder Asperger s Syndrome Disorder of Infancy, Childhood, Adolescence, (not otherwise specified/nos) Medical Necessity Criteria 1. The client must have an included DSM (Diagnostic and Statistical Manual of Mental Disorders) diagnosis. Please refer to list on next slide. 2. The client must have either a serious impairment or the probability of significant deterioration in an important area of life functioning; children also qualify if there is a probability they will not progress developmentally as appropriate. 3. The focus of the proposed intervention(s) is to address the impairment, and it is expected that the client will benefit from the treatment. For children, it is probable the child will not progress developmentally as appropriate without the treatment, or it is expected that the condition will be corrected or ameliorated. Note: The impairment would be non-responsive to physical healthcare-based treatment solely. 6
Target Populations: How do ISFC and TFC Interact? TFC and ISFC target populations may overlap but that does not mean that they will receive both TFC and ISFC services. A child/youth can be assessed as ISFC and not meet medical necessity for TFC A child/youth can be assessed as meeting medical necessity for TFC and not be assessed for ISFC A child/youth can be assessed as meeting the criteria for both ISFC and TFC Funding Sources FFA: Federal Title IV-E, Realignment funds, and County-Only funds. State share of cost for specific purposes (when Proposition 30 kicks in because of a new state mandate). No mental health funding! ITFC: Federal Title IV-E, Realignment funds, and County-Only funds. State share of cost for specific purposes (when Proposition 30 kicks in because of a new state mandate). No mental health funding! ISFC: Federal Title IV-E, Realignment funds, and County-Only funds. State share of cost for specific purposes (when Proposition 30 kicks in because of a new state mandate). No mental health funding! TFC: Mental Health funding only split between a 50/50 equal match between federal Medi-Cal EPSDT Funds (Title 19) and Realignment funds or County-Only Funds. No State share of cost and no federal Title IV-E funding at all. No funding for care and supervision or room and board! 7
Role of Resource Parent FFA: FFA parents are trained to provide care and supervision in Level of Care 1-4 ITFC: ITFC parents are highly trained to provide intense care and supervision for youth with high-needs and behaviors ISFC: ISFC parents are highly trained to provide intense care and supervision for youth with high-needs and behaviors TFC: TFC parents are highly trained to provide specialty mental health activities and services in the TFC service model What Makes the Role of a TFC Parent Different than Regular Foster Care? The TFC parent must: Obtain a National Provider Identification (NPI) for Medi-Cal authorization in order to have the therapeutic services they provide as Specialty Mental Health Services activities billed to Medi- Cal/EPSDT Obtain a Rendering Provider number from the MHP Use a taxonomy code Complete progress notes for each day of service that meet Medi- Cal specialty mental health service documentation standards Maintain the Health Insurance Portability and Accountability Act requirements 8
What Makes the Role of a TFC Agency Different than Foster Care Agencies? The TFC Agency must: Provide a Licensed Mental Health Professional (LMHP) or Waivered or Registered Mental Health Professional (WRMHP) to review and co-sign each progress note to indicate that service activities and that documentation requirements are met Have the LMHP/WRMHP meet face-to-face with the TFC parent a minimum of 1 hour per week to review the treatment plan and ensure Medi-Cal SMHS service activities are met TFC home will not need to have a Medi-Cal site certification What are the Requirements from DHCS to be an FFA TFC Agency? The TFC Agency needs to be an FFA that also meets Medi-Cal SMHS provider requirements and be certified by the county Mental Health Plan (MHP) as a Medi-Cal provider, and have a contract with the MHP to provide SMHS as a TFC Agency The County Mental Health Plan is responsible for certifying and monitoring the private FFA TFC Agency to ensure SMHS requirements are met The DHCS will conduct the Medi-Cal certification for a county owned and operated FFA TFC Agency 9
Age and Educational Differences in Parent Qualifications FFA: Minimum age of 18 No minimum educational requirement ITFC: Minimum age of 18 No minimum educational requirement ISFC: Minimum age of 18 No minimum educational requirement TFC: Minimum age of 21 years Must have a high school degree or higher or equivalent Minimum Training Hours for Parents FFA: 12 hours pre-approval 8 annual post approval ITFC: 40 hours pre-approval 32 within first 12 months after placement of an ITFC child 12 annual each year thereafter ISFC: 40 hours pre-approval 24 within first 12 months after placement of an ISFC child 12 annual each year thereafter TFC: 40 hours TFC parent training pre-approval 24 annual each year thereafter with an emphasis on skill development and application of SMHS knowledge acquisition 10
Training Hours for Two-Parent Homes FFA: Not applicable because only one parent in a two-parent home is required to be RFA trained and RFA approved (but both need criminal clearances). Training is the same if second parent is a Resource Parent ITFC: First parent: 40 hours pre-approval Second parent: 40 hours of pre-approval 20 within first 12 months after placement - 20 within six months after placement 12 annual each year thereafter - 12 annual each year thereafter ISFC: First parent: 40 hours pre-approval Second parent: 20 hours of pre-approval 24 within first 12 months after placement - 20 within 12 months after placement 12 annual each year thereafter - 12 annual each year thereafter TFC: Two-Parent Households are not addressed Can Foster Parent or RFA Training Hours be Applied to Satisfy Some of the Training Requirements? ITFC: Yes training hours incurred by a Foster or a Resource Parent can be applied towards the pre, ongoing and annual training hours ISFC: Yes training hours incurred by a Foster or a Resource Parent can be applied towards the pre, ongoing and annual training hours Also, training hours received to be a Special Health Care Needs resource parent can be applied TFC: Not sure about ITFC and ISFC Training topics to satisfy some of the TFC training hours. (?) 11
Are There Waivers to Pre-Approval Training Hours for Parents FFA: NO - No waivers for training hours before approval as a FFA Resource Family ITFC: YES - Upon approval of the county interagency review team or the county placing agency, the training requirements may be waived for foster parents with prior experience that includes, but is not limited to, working for at least one year with emotionally disturbed children or children who have a serious behavioral problem ISFC: YES an ISFC family may have the pre-approval training hours waived to accept or retain an eligible ISFC child under certain conditions: One-parent household: the initial 40 ISFC training hours are completed within 120 days Two-parent households: the second parent has to complete the initial 20 hours within 180 days Training hours within 12 months and annually as required TFC: NO No waivers for the 40 hours of TFC parent training Differences in Training Topics Between ISFC and TFC ISFC: In addition to the training required to become a Resource Parent, an ISFC parent needs training on: Providing care and supervision to children and youth with intensive medical, therapeutic or behavioral needs Specific subject matters may be customized to each ISFC family based on the population of children the family intends to serve (CSEC, AWOL, Medically Fragile, Sexual Offender, etc.) Additional training may be required by the county placing agency depending on the special needs of an eligible child 12
Differences in Training Topics Between ISFC and TFC (continued) TFC: In addition to the training required to become a Resource Parent, a TFC parent needs training in: Introduction to Therapeutic Foster Care services The role of a TFC parent in mental health treatment planning and the role and performance as a therapeutic change agent Case records and documentation Progress note training/medical necessity criteria Crisis management/de-escalation techniques HIPAA Access to other medically-necessary Specialty Mental Health Services Understanding plan development; rehabilitation and collateral under EPSDT Can a Child or Youth in a STRTP Receive TFC? NO TFC for STRTP Placements TFC is only available for children and youth living with Resource Parents approved by an FFA (can be a public county operated FFA) A youth stepping down from a STRTP could be served in a TFC home while transitioning to home based care 13
CCL and Program Statement Requirements FFA: The FFA needs to describe their Resource Family, the delivery of core services and supports and other items in an approved DSS CCL program statement ITFC: The FFA should have described their ITFC program in an approved DSS CCL program statement but this was inconsistently applied by both the FFA and CCL ISFC: The FFA needs to describe their ISFC model including identifying the staff delivering core services and supports, describing the manner in which core services and supports are delivered, and the necessary professional and paraprofessional staff and social workers in an approved DSS CCL program statement TFC: TFC is not under the jurisdiction of DSS CCL but is under the jurisdiction of California Department of Health Care Services (DHCS) MOU Requirement and State Approved County Plan FFA: No unless required by the county placing agency ITFC: Yes it s the law for the ITFC Agency to have a MOU with the county placing agency Counties need to apply and receive State approval to have an ITFC rate for FFAs to provide ITFC ISFC: No unless required by the county placing agency Counties DO NOT NEED to apply and receive State approval for an ISFC rate for FFAs to provide ISFC TFC: Not an MOU unless required by a county but the TFC Agency needs to obtain a contract with a County Mental Health Plan to provide SMHS TFC Services 14
Respite Requirement FFA: No - Respite is not required ITFC: Yes - Respite is required ISFC: Not sure - Respite is not addressed in the new statute as a requirement but is a best practice TFC: No - Respite is not required Capacity: Number of Children Allowed in the Home FFA: No more than SIX children total including biological, nonminor dependents, foster, adopted and guardianship (exceptions for up to EIGHT for sibling groups) ITFC: No more than ONE emotionally disturbed child or child who has a serious behavioral problem unless FFA provides county placing agency written assessment of the risk and compatibility of placing together TWO ITFC youth. To keep siblings together, MORE THAN TWO ITFC youth may be placed together. ISFC: No more than TWO ISFC children can be placed together. Prior to placing two ISFC youth or a subsequent foster child, the FFA shall provide each county placing agency with a written assessment of the risk and compatibility and obtain approval TFC: Per the Medi-Cal Manual, it is more desirable to have only ONE child/youth receiving TFC SMHS placed in a TFC home. In some, limited circumstances, it can be in the best interest of the child/youth for there to be TWO children/youth placed in a TFC home, for instance, to keep a sibling group together 15
Social Worker to Client Ratio FFA: 1:15 social worker to client ratio ITFC: 1:8 social worker to client ratio ISFC: No ratio stipulated other than adhering to the minimum FFA social worker to client ratio TFC: Not applicable social worker personnel only applies to the FFA foster care side. The TFC Agency assigns a Licensed Mental Health Professional to the family no ratio specified ISFC Client Support Staff (NEW: Not required for FFAs, ITFC or TFC) For ISFC only: The new ISFC program requires client support staff defined as professional and paraprofessional staff or contractors who meet experience and education requirements and are operating within the scope of practice of their license or certification, to provide support and services to the eligible child and other individuals Client support staff shall review the individual needs and services plan with the ISFC parents and the CFT as needed 16
Client Support Staff Training Hours ISFC Client Support Staff 40 hours training before being assigned responsibility to an ISFC family 20 hours of ongoing in-service training within first 12 months after becoming an ISFC client support staff Annual hours are not referenced in the new ISFC statute Training Hours for Client Support Staff when the ISFC Child is Special Health Care Needs (i.e. a nurse) ISFC Training Hours for Client Support Staff Serving Special Health Care Needs Professionals may be employed as staff or contractors operating within the scope of practice of their license or certification to implement the needs and services plan and individualized health care plan (i.e. nurses may be hired under ISFC) For ISFC client support staff caring for SHCN foster youth, required training hours maybe satisfied by training received for the SHCN program and by training hours required by the licensing board within their scope of practice (i.e. CEUs required of licensed nurses) 17
Educational Requirements for Client Support Staff ISFC Client Support Staff Educational Requirements (at least one of the following): Minimum of a bachelor s degree and six months of experience working with children who have serious emotional or behavioral needs or children who have special needs, including, but not limited to, intensive medical needs Minimum of an associate s degree and one year of experience working with children who have serious emotional or behavioral needs or children who have special needs, including, but not limited to, intensive medical needs Educational waivers allowed for client support staff who have direct client supervision with at least two years experience working with this population (also need to demonstrate skill in working with target populations) Total Agency Reimbursement FFA: LOC 1 LOC 4 minimum reimbursement rates range from $2,139 - $2,618 ITFC: Levels I, II and III minimum reimbursement rates range from $5,892 $4,345 ISFC: One level/one rate is $6,092 TFC: The FFA TFC receives a maximum of the interim rate of up to $87.40 per day paid by the Mental Health Plan (MHP) at a rate that is negotiated between the MHP and the TFC Agency 18
Agency Program Reimbursement (does not include caregiver s stipend) FFA: FFAs caring for youth in LOC 1 LOC 4 receive a minimum reimbursement rate for the provider s activities ranging from $1,216 $1,383 ITFC: ITFC Programs caring for youth in Levels I, II and III receive a minimum reimbursement rate for the provider s activities ranging from $3,482 $1,935 ISFC: ISFC Programs caring for youth in ISFC receive a minimum reimbursement rate for the provider s activities of $3,682 TFC: Amount is flexible because each FFA TFC will provides the TFC parent a portion of the interim rate of up to $87.40 per day as determined between the family and the TFC Agency Resource ITFC ISFC -TFC Parent Reimbursement Minimum Rate FFA: Resource Parents caring for youth in LOC 1 LOC 4 receive a minimum reimbursement rate ranging from $923 $1,235 ITFC: ITFC Parents caring for children in Levels I, II and III receive a minimum reimbursement rate of $2,410 ISFC: ISFC Parents receive a minimum reimbursement rate of $2,410 TFC: Amount received by the TFC parent is flexible because each FFA TFC will provide the TFC parent a portion of the interim rate of up to $87.40 per day determined by that TFC Agency 19
TFC Reimbursement The TFC Up to $87.40 per diem covers: The TFC Agency s administrative and LMHP/WRMHP staff costs The payment to the TFC parent for the SMHS components provided through the TFC service model to the child or youth living in the TFC home Recruiting and training TFC parents Private Pay Clients - Can the Agency and the Home Provide Services to Non Foster Youth? YES- FFA, ITFC, ISFC and TFC Programs may accept private pay clients Children and youth who do not have an open child welfare case can receive services in any of the homes below but there is no payment from child welfare to pay for care and supervision or supports and services for non-foster youth. That has to be negotiated with the private payer Example: Kaiser clients; Special Education Students 20
Allowance of In Lieu of In Home Support Counselor Hours When the interagency review team or county placing agency and the FFA agree that alternative services are in the best interests of the child, the FFA may provide or arrange for services and supports allowable under California s foster care program in lieu of in-home support counselor hour support services FFA: Not applicable ITFC: Yes ISFC: Not applicable because ISFC eliminated the requirement for In Home Support Counselor hours TFC: Not applicable Interim ITFC Service and Rate Levels and In Home Support Counselor Hours (Effective July 1, 2012- December 31, 2016) Service and Rate Level Required In-Home Support Counselor Hours Level I Level II Level III 81 114 hours 47 80 hours Less than 47 hours 21
Mental Health Contract Requirements FFA: NO ITFC: NO - unless a county requires it as part of a MOU ISFC: NO - unless a county requires it as part of a MOU TFC: YES a Medi-Cal site certification will be required for the TFC Agency and the FFA needs to obtain a contract with a County Mental Health Plan to provide SMHS TFC Services. Steps for Organizations to Provide EPSDT SMHS Obtain MediCal provider certification Obtain contract with county mental health plan(s) Obtain authorization to provide individualized services to individual youth 22
Mental Health Progress Notes FFA: Not required ITFC: Not required ISFC: Not required TFC: YES - There is a requirement for the FFA TFC Agency to be responsible for the oversight of progress notes related to the TFC parent and the child or youth Resource Parent Qualifications: Medi-Cal National Provider Identifier (NPI) FFA: NO ITFC: NO ISFC: NO TFC: YES - TFC parent DOES bill EPSDT (the FFA takes care of the billing) and DOES need a National Provider Identifier (NPI) 23
ISFC and TFC Contracts and Programs Experiences of Providers and Counties in the TFC Contract Process County Expectations Recruitment and Training of ISFC or TFC Families Best Practices Serving High Needs Youth Obstacles Advice Questions? 24