collaborating to finance behavioral health services for children and their families
DESCRIPTION
Collaborating to Finance Behavioral Health Services for Children and Their Families. SAMHSA/CMS Conference on Medicaid and Mental Health Services and Substance Abuse Treatment Arlington, VA September 2006 Beth Stroul, M. Ed . Frank Rider, MS Denise Baker. Literature Review. - PowerPoint PPT PresentationTRANSCRIPT
Collaborating to Finance Collaborating to Finance Behavioral Health Behavioral Health
Services for Children Services for Children and Their Familiesand Their Families
SAMHSA/CMS Conference on Medicaid and Mental Health Services and Substance
Abuse Treatment
Arlington, VASeptember 2006
Beth Stroul, M. Ed.
Frank Rider, MS
Denise Baker
Literature ReviewLiterature Review
Fragmented Funding
Funding sources for children's mental health services include a complex patchwork of funding streams across multiple systems
Financing of children’s behavioral health services is irrational, fragmented, categorical, and inflexible
Often does not support a full array of home and community-based services and supports
Disproportionate share resources are spent on residential and inpatient treatment
Results in cost shifting across systems
Literature Review Literature Review
Medicaid Funding
Over the past 15 years, states have increasingly relied on Medicaid to pay for health and mental health services
Medicaid budgets have escalated in states
Managed care technologies have been applied in most state’s Medicaid systems
Medicaid plays a key role in financing children’s mental health systems of care
Literature ReviewLiterature ReviewEffective Medicaid Financing Strategies:
Collaborative strategies for Medicaid dollars
Redirect spending from "deep-end" restrictive placements to home and community-based services and supports
Incorporate strong utilization and cost management mechanisms and systematically track costs
Incorporate case rate and risk adjustment strategies if operating within risk-based environments
Use behavioral health carve outs
Study of Effective Financing Study of Effective Financing Strategies for Systems of CareStrategies for Systems of Care
Goals
Develop better understanding of critical financing structures and strategies to support effective systems of care
Examine how these financing strategies operate separately, collectively, and in the context of states and communities
Promote improved financing policies through dissemination of study findings and TA to states and communities
Study HypothesesStudy HypothesesEffective Financing Strategies:
Identify Current Spending and Utilization Patterns Across Systems Determine utilization and costs
Identify types and amounts of funding for behavioral services
Realign Funding StreamsUtilize diverse funding streams
Maximize the flexibility of state and/or local funding streams
Coordinate cross-system funding
Maximize federal entitlement funding (Medicaid, SCHIP, IV-E)
Redirect spending from "deep-end" restrictive placements to home and community-based services and supports
Financing to support a locus of accountability for managing care and costs for high-need populations
Finance services to uninsured and underinsured children
Study HypothesesStudy Hypotheses
Finance an Appropriate Array of Services and Supports Support a broad service array Promote individualized, flexible service delivery Support and provide incentives for the provision of
evidence-based and promising practices Promote and support early identification and
intervention and early childhood mental health services Support cross-agency service coordination/care
management
Support Family and Youth Partnerships Support family and youth involvement in policy-making Support family and youth involvement and choice in
service planning and delivery Support services and supports to families/caregivers
Study HypothesesStudy Hypotheses
Financing to Improve Cultural/Linguistic Competence and Reduce Disparities in Care
Support culturally and linguistically competent services
Reduce racial/ethnic disparities in access
Reduce geographic disparities in access
Financing to Improve the Workforce and Provider Network
Support a broad, diversified, qualified workforce and provider network
Provide adequate provider payment rates
Study HypothesesStudy Hypotheses
Financing for Accountability Incorporate utilization, quality, and cost management
mechanisms
Utilize performance-based or outcomes-based contracting
Evaluate financing policies to ensure that they support and promote system of care goals and continuous quality improvement
Support leadership, policy, and management infrastructure for systems of care
Study MethodsStudy Methods
Participatory Action Research Approach
Continuous dialogue with key users on study methods
Multiple Case Study Design
10 site visits and 5 additional sites for telephone interviews
Panel of national financing experts nominated potential sites for the study
Sites demonstrate effective financing strategies in multiple domains
Sites demonstrate commitment to system of care philosophy and approach
Critical Financing Areas Critical Financing Areas
Identification of Current Spending and Utilization Patterns Across Systems for Strategic Planning
Realignment of Funding Streams and Structures
Financing of Appropriate Services and Supports
Financing to Support Family and Youth Partnerships
Financing to Improve Cultural/Linguistic Competence and Reduce Disparities in Care
Financing to Improve the Workforce and Provider Networks for Behavioral Health Services for Children and Families
Financing for Accountability
Selected SitesSelected Sites
Selected Sites for First Wave of Site Visits
Maricopa County, Arizona
State of Vermont
Bethel, Alaska
State of Hawaii
Central Nebraska
Telephone Interviews
Milwaukee Wraparound, Wisconsin
Dawn Project, Indianapolis, Indiana
State of New Jersey
Site VisitsSite Visits
Site visits involve interviews with key informants
Use of semi-structured interview protocol
Explore the implementation of critical financing strategies and challenges in each area
ProductsProducts
Self-assessment and planning guide for state and community policymakers and planners to develop a comprehensive financing plan
Financing TA briefs with “how-to” information and examples from the site visits
Technical assistance to states and localities by partners
A Self-Assessment and A Self-Assessment and Planning Guide:Planning Guide:
DDeveloping a eveloping a Comprehensive Financing Comprehensive Financing Plan to Support Effective Plan to Support Effective
Systems of CareSystems of Care
A Technical Assistance Tool for States, Communities, and Tribes
Purpose of Self-Assessment Purpose of Self-Assessment and Planning Guideand Planning Guide
To assist states, communities, and tribes to: Assess their current financing structures and
strategies
Identify outcomes to achieve
Consider a variety of financing strategies
Prepare to develop a strategic financing plan
Not designed to provide detailed “how to” information for each strategy
Products with “how to” information will follow site visits
Identification of Current Spending and Utilization Patterns Across Systems
Realignment of Funding Streams and Structures
Financing of Appropriate Services and Supports
Financing to Support Family and Youth Partnerships
Financing to Improve Cultural/Linguistic Competence and Reduce Disparities
Financing to Improve the Workforce and Provider Network
Financing for Accountability
Glossary
Links to Other Resources
Areas Addressed in the GuideAreas Addressed in the Guide
How to Use the Guide How to Use the Guide
Deciding Where to Begin
What key stakeholders feel should be done first
Which strategies are in place and which need to be developed
Which strategies would provide short-term “wins” and which are longer-range
Which areas of guide would be most useful now
Selecting Outcomes
Reviewing and Selecting Strategies
Example – Realigning Example – Realigning Funding StreamsFunding Streams
Outcome
Increased proportion of funding used for home and community-based services in relation to funding for more restrictive services
Potential Strategies to Consider Medicaid home and community-based waivers
Redirection of funds from bed closures and reduction in residential placements to community-based services and supports
Offer therapeutic foster care as alternative
Offer TEFRA as Medicaid option
Direct new monies to home and community-based services
Example – Realigning Example – Realigning Funding StreamsFunding Streams
More Strategies:
Define medical necessity and level of care criteria to allow for diversion from inpatient and residential care
Include residential providers in discussions about funding issues in moving to a community-based system
Provide TA and training to residential providers for developing home and community-based services and short-term psychiatric stabilization
Involve families in identifying the community-based services and supports that are needed and in advocating for the shift from residential to home and community-based services
Select Strategies and Develop Implementation Plan
Anticipated Outcomes of Financing Study
Revise and finalize set of critical financing strategies
Increased knowledge about and attention to critical financing strategies on the part of key stakeholders involved in building systems of care
Increased use of strategic financing plans for systems of care
FAMILY-RUN
ORGANI-ZATIONS:
F.I.C.
and
MIKID
FEDERAL GOVERNMENT HEALTH AND HUMAN SERVICES
ARIZONA STATE GOVERNMENT
(Appropriations)
ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS) DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS)
REGIONAL BEHAVIORAL HEALTH AUTHORITIES (RBHAs) and TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHAs)
SUBCONTRACTED PROVIDERS
SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION
(SAMHSA)
CENTER FOR MEDICARE AND MEDICAID SERVICES
(CMS)
$
$
$
$
$
$
Arizona’s Behavioral Health System
13287
7270
20122
10530
19225
10217
27580
14316
28488
14725
34924
18892
34368
17199
39020
20041
0
5000
10000
15000
20000
25000
30000
35000
40000
2000 2002 2004 2006
Arizona T-19
Maricopa T-19
Arizona Total
Maricopa Total
Rapidly Expanding EnrollmentJune 2000 - June 2006
Arizona BH Funding for Children
FUND SOURCE FY 2006 FUNDS TOTAL
FY 2006 FUNDS
Children’s
Percent ofChildren’s $
Medicaid/Title XIX(67.4% federal)
$760,640,800
$269,079,100
88.68%
SCHIP/Title XXI(77.185% federal)
$15,130,000
$15,130,000
4.99%Federal Grants
$44,631,300
$10,981,200
3.62%
County Funds (Maricopa, Pima)
$39,161,500
$1,803,000
0.59%State Appropriations
$117,516,600
$6,444,600
2.12%
Other
$3,778,200
0
0.00%
Total Funding
$980,858,400
$303,438,500
100.00%
Arizona Financing Features Pre-paid capitation (per member, per month)
Service planning process that engages positive contribution of families
Service planning process that attracts informal supports
Broad array of service/support options
Minimal prior authorization
Risk-adjusted capitation for children in state custody
Flexible funds
The Arizona Vision
“In collaboration with the child and family and others,
Arizona will provide accessible behavioral health services
designed to aid children to: achieve success in school live with their families avoid delinquency become stable and productive adults
Services will be tailored to the child and family and provided in the most appropriate setting, in a timely fashion, and in accordance with best practices, while respecting the child’s and family’s cultural heritage.”
J.K. vs. Eden et al. No. CIV 91-261 TUC JMR, Paragraph 18
The 12 Arizona Principles
Collaboration with the Child and Family
Functional Outcomes
Collaboration with Others
Accessible Services
Best Practices
Most Appropriate Setting
Timeliness
Services Tailored to the Child and Family
Stability
Respect for the Child and Family’s Unique Cultural Heritage
Independence
Connection to Natural Supports
Principle: Collaboration with the Child and Family
Families mobilized to participate in collaborative workgroups (in the settlement process phase of JK litigation)
Maricopa Co. RBHA hired parent as a Systems Development leader (JK 300 Kids Pilot)
Arizona Children’s Executive Committee established Family Involvement Subcommittee
Policy established to compensate family members for their expertise
White paper written defining scope and nature of family involvement
Framework embraced by all Arizona child-serving agencies
“Family Involvement Framework”
adopted by Arizona Children’s Executive
Committee
“Family Involvement Framework”
adopted by Arizona Children’s Executive
Committee
Importance of Family-Run Organizations
Mental health care is consumer and family driven The President’s New Freedom Commission Goal #2
Family-Run Organizations as Transformation Agents Gary Blau, SAMHSA/CMHS – Federation of Families for Children’s Mental Health Conference 2005
“Market Research”/Participatory Action Research What the customer needs, and how they want it
Persistent commitment to long-term change process
Provide wide array of enhancement to public system transformation efforts
Statewide Family Networks (47 states)
Arizona’s Family-Run Organization Partnership: MIKID and Family Involvement Center
Shared Commitment among Key Partners: Families, State, RBHAs, Community
Example: St. Luke's Health Initiative (foundation) provided pilot funding:
Stipends
Consultative Resources
Training and Outreach
Families Organize in Arizona
Covered BH Services in AZ
Prevention Services
Rehabilitation Services
Support Services
Treatment Services
Medical Services
Behavioral Health Day Programs
Crisis Intervention Services
Inpatient Services Residential Services
New Focus on Support and Rehabilitation Services
Support ServicesCase ManagementFamily Support Peer Support Respite CareTransportation
Rehabilitation ServicesLiving Skills Training Health Promotion
Service Coding, FFS rates designed to support community-based service delivery
(Reference ADHS Covered BH Services Guide at: http://www.azdhs.gov/bhs/bhs_gde.pdf)
Delivered byProfessional, BH Technician, Para-professionals
New Types of ProviderCommunity Service Agency [CSA]Therapeutic Foster Care [TFC]Habilitation
Child and Family Team Process
“The Child and Family Team is a group of people that includes, at a minimum, the child, the child’s family, any foster parents, a behavioral health representative and any individuals important in the child’s life who are identified and invited to participate by the child and family.”
1. Engagement 6. Plan Development
2. Immediate Crisis Stabilization 7. Plan Implementation
3. Strengths, Needs and Culture 8. Crisis Planning Discovery
4. Team Formation 9. Tracking and Adapting
5. Team Facilitation 10. Transition
From ADHS Practice Improvement Protocol #7: “The Child and Family Team”
Child and Family Team (CFT) Process
Based on the Wraparound Approach:Service planning is family-centered, strength-based, highly individualized, culturally competent and collaborative across systems, promoting reliance on informal and natural supports in combination with formal supports and services.
Congruent with: Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)
Clinical Guidance Documents
Operationalize Principles
Memorialize Expectations
Developed through Collaborative Processes
“Guidance” Contractual Requirements
Examples:
Child and Family Team PIP and TAD
Reference:
http://www.azdhs.gov/bhs/guidance/guidance.htm
Families Join the Behavioral Health Workforce
Family Support Partners Work alongside case managers and clinicians to ensure effective family
voice within Child and Family Teams Today over 70 family members are employed in provider agencies Juvenile Justice: Parent Liaisons (early implementation) Child Welfare: Parent Mentors (role being developed)
Provision of Direct Family-to-Family Services Family Support (Home Care Training) Peer Support Peer Support Group Skills Training Skills Training Group Behavioral Health Promotion Education & Training Respite
Benefits of Family Support as a Behavioral Health Service
Prepares families to benefit from clinical services
Increases value of clinical services
Leverages cost-effective natural supports
Enhances workforce with skilled, committed members:
• para-professional, technical skills complement professional services
• Well-trained, experienced personnel (family organization/CSA or OBHL-licensed clinic)
• Workforce that resembles the people we serve
• Mitigates nationally-strained BH workforce limitations
System Transformation and Service Delivery Funding
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
FIC Funding Allocation
State Systems Transformation
RBHA Systems Transformation
RBHA Medicaid Services
Other
Therapeutic Foster Care: A Programming Success Story
Family-Based Alternative to Congregate Care
Braiding Medicaid and Title IV-E Resources
ADHS Practice Improvement Protocols:
• Therapeutic Foster Care Services for Children
• Out of Home Care Services
Recruitment, Licensing and Certification
PS-MAPP and TFC Advanced Curriculum
TFC Capacity Growth:
• September 2003 – 9 placements statewide
• September 2006 – 404 placements (40% of all OOH)
Reduced Out of State Placements
100
38
15 13
25
0
20
40
60
80
100
120
Jun-02 Jun-03 Jun-04 Jun-05 Jun-06
Jun-02Jun-03Jun-04Jun-05Jun-06
Family Partnership with MCO’s: Wide Array of Key Roles within Arizona’s
Family-Driven System of Care
Involvement in recruitment, hiring, creating job descriptions, shaping supervision guidelines
Development of practice protocols
(Co-)Trainers for BH workforce
Consultative resources
Continuous Quality Improvement roles (example: Arizona CFT process measurement)
Quality Management Processes
CFT Process Measurement’s Four Big Questions:
1. Has a trusting relationship been established with the family (engagement)?
2. Does the Child and Family know the family and has it identified the strengths needs and culture of the family?
3. Has an Individualized Service Plan been created that meets the needs of the child and family?
4. Is the team implementing, monitoring and modifying the service plan toward a successful outcome for the child and family?
Quality Management:CFT Process Measurement
Fall 2005 Reviews
Region A – 67.8%
Region B – 64.1%
Region C – 74.1%
Region D – 66.3%
Region E – 73.3%
Region F – 41.7%
Statewide: 53.25% [n = 486]
Winter 2006 Reviews
Region A – 70%
Region B – 64%
Region C – 71%
Region D – 61%
Region E – 81%
Region F – 53%
Statewide: 60.45% [n = 418]
Improved Processes Improved Outcomes
Wraparound Milwaukee: Residential placements
decreased by 60% Psychiatric hospitalization
decreased by 80% Reduced recidivism by
delinquent youth Decreased overall cost of
care per child
Bruce Kamradt, Child Welfare League of America, 2001 National Conference;
and Report of the Surgeon General on Children’s Mental Health (1999)
Project MATCH/Pima County AZ:
High fidelity CFT practice connected to significantly better outcomes than low fidelity CFT practice on standardized measures:
Child/Adolescent Functioning [CAFAS]
Child Behavior Checklist [CBLC]
Restrictiveness of Living
Environment Scale [ROLES]
Family Resource Scale [FRS]
Rast, O’Day, Bruns & Rider, 17th Annual Research Conference
in Children’s Mental Health (2004)(n = 63 CFTs, fidelity per WFI 2.1, -6 to +12 months)
Outcomes for Arizona Children
with/without Child and Family Teams (5-11 y.o.)
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
CFTNo CFTCFT 74.0% 69.2% 72.5% 57.4% 64.2% 87.0%
No CFT 59.5% 58.3% 63.3% 51.1% 53.0% 80.3%
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Outcomes for Arizona Youth with/without Child and Family Teams (12-17 y.o.)
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
CFT
No CFTCFT 70.4% 66.2% 69.7% 57.4% 65.1% 80.2%
No CFT 53.5% 54.8% 58.7% 47.3% 52.5% 75.5%
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Participatory Action Research Approach [PAR]
Participatory action research = collective, self-reflective enquiry undertaken by participants in social situations in order to improve the rationality and justice of social practices. Kemmis and McTaggart (1988)
The four components of action research are: 1. Observation 2. Reflection
3. Planning 4. Action
How Arizona families participate in PAR: Session Rating Scales (Family to Family services) Outcome Assessment (within CFT process) CFT Process Measurement JK Annual Planning Process JK Committee
A Few Last Words… Medicaid Administrators - Families have much to
offer: expertise about what works and what doesn’t work can work in partnership with treatment professionals to provide
necessary and cost-effective services
Mental Health/Substance Abuse Administrators - Consumers and families are a traditionally untapped sources of
expertise about effective service delivery approaches Resources (e.g. funding) must be designated to leverage their
transformational voices Avoid tokenism – prepare, support families as you do all other
experts
Family Members - Be part of the solution (“non-adversarial advocacy”) Organize to ensure a family-driven system of care
Denise Baker, Parent/Consultantc/o The Family Involvement Center, Phoenix AZ [email protected]
Frank Rider MS, DirectorArizona Institute for Family Involvement
Beth Stroul M.Ed., Vice President Mgmt. & Training Innovations Inc., McLean VA
For further information: