Addressing the Challenge of Substance Use: A State and Community Approach Presented by: Elizabeth Manley, Institute for Innovation and Implementation Kathi Way, Acting Assistant Commissioner, NJ Children s System of Care Kathy Collins, Executive Director, Monmouth Cares Marc Fishman, MD Medical Director Maryland Treatment Centers
Federal Legislation: Joint CMCS and SAMHSA Informational Bulletin 1/6/15 Protecting Our Infants Act of 2015 provides the framework to address the challenge of prenatal opioid exposure. Neonatal Abstinence Syndrome (NAS) Prenatal Opioid Exposure Treatment of Opioid Use Disorder (OUD) CDC Guidelines for Prescribing Opioids for Chronic Pain
Federal Legislation Continued: Comprehensive Addiction and Recovery Act (CARA): included: increased access to naloxone Improved prescription monitoring programs Increase access to treatment programs Training for professionals 21 st Century Cures Act: CMCS Informational Bulletin Requirements of providing all medically necessary treatments for individuals under 21 Research and drug development Opioid epidemic Informed consent
Federal Legislation Continued: Family First Act of 2018 Provides for the ability to fund Residential SU treatment for families. Allows for funding mental health and substance use treatment Pending Legislation:
https://www.medicaid.gov/federal-policy-guidance/downloads/cib-11-28-12.pdf https://www.medicaid.gov/federal-policy-guidance/downloads/cib-05-07-2013.pdf http://www.aecf.org/blog/family-first-prevention-services-act-will-change-the-lives-of-children-in-f/ https://www.congress.gov/114/plaws/publ255/plaw-114publ255.pdf https://gucchd.georgetown.edu/products/financebrief_hcbservices.pdf http://nasadad.org/wp-content/uploads/2016/07/cara-section-by-section-july-2016.pdf
1 Trust, Transfer, Transition, Integration, Transformation How the NJ Children s System of Care Assumed Responsibility for Adolescent Substance Use Treatment Kathryn Way, Acting Assistant Commissioner July 2018
Department of Children and Families New Jersey Department of Children and Families Commissioner Children s System of Care (formerly DCBHS) Child Protection & Permanency (formerly DYFS) Family & Community Partnerships (formerly DPCP) Division on Women Office of Adolescent Services
Children s System of Care Serves youth under age 21 with emotional and behavioral health care challenges, intellectual/ developmental disabilities, Autism, and/or substance use challenges CSOC is committed to providing these services based on the needs of the youth and family in a family-centered, community-based environment Statewide services with access through single point of entry Voluntary Medicaid platform Local System partners are located in the community and aligned with Court Vicinages to assure seamless connections and coordination of care, particularly where youth have multisystem involvement
Children s System of Care Objectives To Help Youth Succeed 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.
Service Array Expansion to Reduce Use of Deep End Services Low Intensity Services Out of Home Out of Home Intensive In- Community Wraparound CMO Behavioral Assistance Intensive In-Community Lower Intensity Services Outpatient Partial Care After School Programs Therapeutic Nursery Prior to Children s System of Care Initiative Today
System of Care Values and Principles Youth Guided & Family Driven Community Based Culturally/Linguistically Competent Strength Based Unconditional Care Promoting Independence Family Involvement Collaborative Cost Effective Comprehensive Individualized Home, School & Community Based Team Based
Language Is Important Our language conveys are attitudes and values Language can hurt, label, stigmatize Client Case Placement Instead of addict/addiction, say substance use challenges Instead of rehab, say treatment intervention Instead of compliance, say engagement Instead of abuse, say use
Trauma-Informed Care Departmental Initiative. Do not focus on surface behavior. Interventions should address underlying trauma reaction Implicit trauma indicators Safe, consistent, nurturing environment The Six Core Strategies for Reducing Seclusion and Restraint Use
Children s System of Care History 1999 NJ wins a federal grant that allowed us to develop a system of care. 2006 The Department of Children and Families (DCF) becomes the first cabinet-level department exclusively dedicated to children and families [P.L. 2006, Chapter 47]. January 2013 Intellectual/developmental disability (I/DD) services for youth and young adults under age 21 is transitioned from the Department of Human Services (DHS) Division of Developmental Disabilities to the DCF Children s System of Care (CSOC).** July 2013 Substance use treatment services for youth under age 18 is transitioned from DHS, Division of Mental Health and Addiction Services, to DCF/CSOC. July 2015 NJ wins a Federal SAMHSA Grant for System of Care - Expansion and Sustainability 2000-2001 NJ restructures the funding system that serves children. Through Medicaid and the contracted system administrator, children no longer need to enter the child welfare system to receive behavioral health care services. 2007 2012 The number of youth in out-ofstate behavioral health care goes from more than 300 to three.* May 2013 Unification of care management, under CMO, is completed statewide. *How did we do this? Careful individualized planning and the development of in-state options (based on research about what youth need) using resources that were previously going out of state. **Youth with I/DD in OOH programs or at risk of OOH, are transitioned July 2012 December 2014 Integration of Physical and Behavioral Health is initiated in Bergen and Mercer County with expected Statewide rollout
Financing Title XIX Funding -Rehab Option -Targeted Case Mgt Child Welfare Juvenile Justice 1915 like (i) or (c) 1115 Waiver CHIP/SCHIP State Funds Priorities Increase Access tocare EBPs Care Management System Coordination Reduce Institutional Care Particular Populations CSOC Values & System of Care Design Principles Factors that Impact Design Environment Political Perspectives of Leaders Lawsuits/Settlements Crisis/Tragedy Mandates Community Will Economy Structure Government State vs. County Existing Reality Envisioned Ideal Medicaid Agency Locus of Control Leadership Structure
SU Transition-Multilayered Approach and Engagement to Assure Best Chance of Success Governor Signs Order for Integration: 1) Extensive Discussion/Negotiation/Information 2) Sharing with the Sending Division 3) Stakeholder Groups 4) Provider Training/EHR (42 CFR, Part 2) 5) Inclusion of Wrap Around 6) Convert sub use OOH programs to co-occurring model 7) Movement to fee for service, rate increase, and adjustment 8) Clinical criteria and authorizations to assure intensity of need is appropriate 9) Ongoing research on best practices, policy and program development
CSOC Continuum of Services for Substance Use Outpatient Partial Care Co-Occurring Group Home Co-Occurring RTC Withdrawal Management Substance Use Navigator*
Stakeholder Group Part of readiness: Important to engage and provide a forum for system partners to understand CSOC and each other Provided community partners an opportunity to understand potentialchanges Provided treatment providers an opportunity to foresee their own destiny Represented by: Families Service Recipients Care Management Organization (CMO) Outpatient Providers(OP) Out of Home Treatment Providers(OOH) Existing Division (DMHAS) Receiving Division(CSOC) Advocates
Access The most important goal: Easy access for youth andfamilies Routinely, all access to System of Care (CSOC) services are routed through the single point of entry, Contracted Systems Administrator (CSA) Prior to transition from DMHAS, access to substance use services occurred through direct contact with provider agencies It was clear that we needed to adopt and maintain the direct accessprocess This required the System of Care to adjust its process As a result, youth/families may access SU treatment services either via contacting the CSA or contacting a contracted provider directly
Access Who may request services? CSOC System Partners Child Welfare Care Management (Wraparound agencies) Mobile Response Juvenile Court County Representatives Schools Pediatricians Youth and Families
Funding Initially, when the substance use contracts for out of home treatment transitioned to CSOC, they remained as cost reimbursement The CSOC vision was to convert these contracts to Fee for Service (FFS) CSOC developed market based rates on the Medicaid platform, which is congruent to the rest of our system s processes In some instances, the rates were significantly increased FFS model resulted in better utilization management 29
Assessment Agencies are required to use below in order to receive an Intensity of Service (IOS) disposition and a service authorization Maintain the use of ASAM Criteria as the basis for assessment CSOC also integrated the CANS assessment tool CSOC s Bio-PsychoSocial evaluation (BPS) Agencies may also use a standardized SU assessmenttool The authorization process was implemented in order to maintain good data, connect where needed Authorizations are also a precursor to these agencies becoming Fee for Service (FFS) providers The CSA issues a 30-day presumptive authorization to give providers the time to complete the assessment processes
Treatment Approach Simultaneous to the transfer, and ultimately, the transition to the System of Care, we developed a co-occurring substance use and behavioral health trauma based model of treatment It seemed clear to us (based on our years of experience, and supported through research), that youth using some form of substance were also experiencing behavioral health and emotional challenges The greater majority of the youth coming for substance use treatment were referred not only for their use, but rather because of their presenting overt behaviors
Transition to Co-Occurring Model The transitioned OOH SU agencies functioned as primary substance use programs until July 1, 2015. In July 2015 and after many meetings, trainings, and contract alterations, CSOC successfully converted all OOH substance use provider agencies to co-occurring programs with an increased per diem rate and a set of standardized contract deliverables. These transitioned SU OOH programs are now referred to as cooccurring group homes.
Programmatic Changes Programmatic changes were made as a result of transitioning to a co-occurring treatment model: Agencies were now financially supported to expand their staffing to include licensed behavioral health clinicians (including dually licensed clinicians), psychiatry, and nursing as a routine part of their work Increased allied therapies which promotes a holistic approach to care Increased staff-to-youth ratio supervision Inclusion of CMO services for all youth in co-occurring OOH treatment; operated within the CFT model
Co-Occurring RTC s The CSOC continuum was in need of co-occurring RTC services to serve youth who displayed a higher level of behavioral health needs and whose model provided a braided, integrated set of interventions for youth. This was a major step towards true integration of care. Initially, CSOC converted an existing RTC (served only males) to a co-occurring RTC program; this agency hired a well-known consultant who developed a trauma based substance use program for their youth. This program operates at full capacity and has been a great success. In 2015, CSOC awarded two five-bed community-based co-occurring programs for girls via RPF. In 2016, CSOC released another RFP and subsequently awarded an additional 32 co-occurring RTC beds for males and females.
Service Delivery The authorization is the conduit for youth to receive services and for agencies to get paid through what was still a cost reimbursement system. The authorization also opens the electronic record, which is closely governed by the 42 CFR Part 2, to the agency. This allows the agencies to complete treatment plans and to request continued care and/or transition youth to another intensity of services within our system of care. All treatment plans require approval by credentialed care coordinators atthe CSA. Treatment plans are completed cyclically and are reviewed by dually licensed clinicians at the CSA for continued care. All planning for youth in OOH treatment is done under the driving auspices of the Child Family Team.
The Child Family Team Drives the Treatment We need to engage youth and families and meet them where they are at.
Mandated Child Family Teams for Youth in Out of Home Treatment for Substance Use Child Family Team (CFT) A team of family members, professionals, and significant community residents identified by the family and organized by the care management organization to design and oversee implementation of the Individual Service Plan. CFT members should include, but are not limited to, the following individuals: Child/Youth/Young Adult Family Support Partner (FSO) Parent(s)/Legal Guardian Care Management Organization Natural supports as identified and selected by youth and family Treating Providers (in-home, out-of-home, etc.) Educational Professionals Physical Health Providers (pediatrician, specialist) Probation Officer (if applicable) Child Protection & Permanency (CP&P)(if applicable)
Behavioral Health Home (BHH) What it is: CMOs are the designated BHH for Children in NJ Enhancement to the Child Family Team to bring medical expertise to the table What it is not: Not a physical site
Co-Morbidity in Children and Adults Cost Driver Children Adults Behavioral Health Physical Health Co-Morbidity is not as high in Children as in Adultsh chronic conditions 1/3 of Children with Behavioral Health have chronic conditions 2/3 of Adults with Mental Illness CMS will only approve those State Plan Amendments (SPA) that cover both children and adults (lifespan) Assisting children and their families manage a chronic illness will reduce significant costs related to physical healthcare inadults Substance Use Disorder is included in the BHH
Outpatient Services The major change for the outpatient providers is that they adopted the CSOC Bio Psychosocial (BPS) evaluation and the treatment planningmodels. OP providers utilize ASAM and CANS as basis for assessment and continued treatment. OP providers may conduct BPS evaluations as a new revenue path. Over time, we converted all the IOP slots into a time bank with the OP slots. This afforded the agencies and youth the opportunity to participate in treatment based on a clinical review as well as their ability to commit to a set number of sessions per week. This appears to be a more efficient use ofresources. The outpatient providers continue to operate as cost reimbursement.
Withdrawal Management (WM) While the initial transfer of programs did not include any subacute detox resources, the result of the Hurricane Sandy in Fall 2012 resulted in funding for the development of a small program for up to six youth. Curiously, and with great concern, these beds were never used to their maximum capacity. This program has since been relocated to a more central location and utilization has increased.
Successes Integrated Approach to Care-We are able to provide better in-depth care and treatment for youth who are presenting with co-occurring behavioral health and substance use challenges. Linkages- We are in a better position to educate our youth and families through the System of Care infrastructure which has the ability to provide an array of interventions that allow for a wraparound approach. One of the few data points we were able to gain before the transfer, was that youth who had been in one of the OOH programs and were also connected to one of the System of Care s Care Management Organizations had better outcomes in the community As a result, we connected youth with CMO upon the youth s admission to OOH with the intent of the youth transitioning back to their community with a plan of care developed by the Child Family Team to support a development of strong community plan.
Ongoing Challenges CSOC is not fully utilizing available resources during a time of grave concern, in which youth are suffering and not accessing services: Ongoing stigma Alcohol and marijuana continue to be seen as recreational rather than potentially problematic areas, especially re: effects on the developing brain; Substance use agencies are noting difficulty in work force development with regard to hiring dually-licensed clinicians.
Next Steps 1. Reducing Stigma-Words Matter 2. Substance Use Navigators in every county/vicinage Building capacity of BH provider network to identify substance use and Develop techniques to address 3. Continue to refine clinical care 4. Substance Use Consultant (Rutgers University)
Next Steps 5. Education on effective SU prevention strategies to all community partners 6. Leverage CIACC s-csoc s local planning bodies to disseminate information: SU Navigators sit on CIACCs Local county dashboards were enhanced to help communities participate in identifying trends and gaps in services 7. Care Plan Redesign (one youth, one team, one plan)
For more information Children s System of Care: http://www.state.nj.us/dcf/families/csc/ PerformCare Member Services: 877-652-7624 www.performcarenj.org Crisis Text Line, Text NJ to 741741
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Wraparound and Substance Use A Care Management Organization's Experience Kathy Collins, LCSW, Executive Director MonmouthCares
A Care Management Organization is charged with providing kids with moderate to complex needs, and their families, with comprehensive planning and coordination of an Individual Care Plan with attention to 12 life domains. Youth have behavioral health challenges, and may also have intellectual/developmental or substance use, challenges, and chronic medical needs. We develop a Child and Family Team for each family and use Wraparound practice. The CMO is part of a Local System of Care.
Mobile Response and Stabilization Providers Care Management Organization Children s Interagency Coordinating Council (local needs, policy and planning) Family Support Organization System Partners (JJ. CW, ED)
Youth with Substance Use Needs Join us in 2013 - Incentives and Challenges Incentive: Joining a robust 12 year old System of Care with opportunities for support Challenge: Different values and practice principles Incentive: New funds and investments in programs and services Challenge: Rapid growth and the need for new expertise and programming
Incentives and Challenges continued Incentive for both CMO and SU providers: Better access to treatment services Challenges for both CMO and SU: CMO: Serious lack of knowledge of SU treatment SU Providers: Lack of CFT participation, i.e. little collaboration with the Community
Challenging Wraparound Principles Family Voice and Choice nothing about us without us. Family-Doubting e.g. enabling, co-addicted, mistrust of the community Team Based + Collaboration Treatment providers rule. our policy. Team Goals
Individualized - customized Levels, steps, rules how we do things Compliance as progress Individual = denial, enabling Unconditional - make a new plan! Everything is conditional, as part of the treatment plan Multiple opportunities to fail to not complete treatment. Ejection as a treatment strategy
Wraparound Phases CMO Expertise Engagement Substance Use Providers Motivation Care Management Vision and Strengths Marketing Unmet Needs External Pressure Family Support and Culture
Wraparound Phases CMO Expertise Transition Substance Use Providers Discharge to? Family, Detention/Probation, Child Welfare Relapse Prevention Care Management Full CF Team Carries On All Life Domains Aftercare Plan? Community Plan
July 2015 SAMHSA Expansion and Sustainability Grant Six Core Strategies Evidence-based strategies to prevent conflict and violence; to reduce the use of Seclusion and Restraint Adapted to include trauma-focused strategies and to be Family-Driven and Youth Guided All System Partners are expected to incorporate the strategies, with special attention to Out of Home Providers
Six Core Strategies 1. Leadership Toward Organizational Change 2. Use Data to Inform Practice 3. Develop Your Workforce 4. Implement Seclusion, Restraint and Coercion Prevention Tools 5. Full Inclusion of Youth and Family Voice in all Activities 6. Make Debriefing Rigorous
Nurtured Heart Approach A set of strategies to transform the way kids perceive themselves, their caregivers and the world. ABSOLUTELY NO! Refuse to energize negative behavior ABSOLUTELY YES! Constant recognition of success, achievement, and their value
Nurtured Heart Approach, cont. ABSOLUTE CLARITY! Clear and consistent consequences when a rule is broken ********* All providers and partners will be trained to strategically pull the child into new patterns of success. Parents have training too.
Thank you! Kathy Collins, LCSW, Executive Director MonmouthCares kcollins@monmouthcares.org www.monmouthcares.org 732-222-8008 x 104