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RBS: OUT OF THE BOX
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Connect the dots by drawing four straight, continuous lines, without lifting the pencil from the paper.
Nine Dot Challenge:
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CDSS Review Process
Foster Care Program
Foster Care Rates & Eligibility
Fiscal
Fiscal
Fiscal RBS SteeringCommittee
Dept of Mental Health
Legal CCL
?
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Mark LaneBay Area Consortium
RBS Local Implementation Coordinator
TransformingBay Area
Residential Services
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Planning Process
5 Counties
x 3 Departments
= Chaos
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Developing consensus(July 11 TA meeting)
How are we going to work together?
Lead County vs. Shared Coordination vs. Shared Purchase ….
Who decides?
What approach makes sense?
Mission: To work together to help the children and families in our target populations build and sustain whole lives.
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Guiding Principles
Service-based, rather than place-based
Families will be part of the team and the decision-making process
Locally provided continuity of care and services
Culturally competent and strength-based services
Minimal disruptions in connections for youth and families
Focus on safe, stable, permanent living environment
Services customized to meet the family’s unique situation
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DEVELOPING THE MOU
Nature of the Relationship
Vision
Shared expectations
Roles and Responsibilities
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ENGAGING THE PROVIDERSTHROUGH AN RFQ
Refining the Target Population
Restating the Guiding Principles
Outlining the Program Design
Defining the Criteria to Deliver Services
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KEY INNOVATIONS forTRANSFORMING BAY AREA
RESIDENTIAL SERVICES
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Provider InnovationsFlexible use of staff resources
Flexible use of facility-based interventions
Increased trend of community-based interventions
Ongoing and flexible decision-making
Balance between place-based and community-based activities
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Funder Innovations
Building contracts with an assumption of trust and based on anticipated transactions throughout the duration of the project.
Family involvement as a key business practice.
Process-based contracting in which key actions are outlined, agreed-upon, and monitored.
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County Worker Innovations
RBS is seen as an affirmative choice
Use of RBS should be a decision of first resort, rather than last resort
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Next Steps
Issue the RFQ
Engage the qualified providers
Complete the funding model
Outline the Waiver Requests
Plan for Implementation
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Target PopulationsBay Area Consortium
Residentially Based Services
Lois Rutten, Contra Costa County
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Who Are These Youth?
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Phase 1 Target Populations
Family Reattachment– Younger children who are in
placement due to a combination of family disruption, abuse and/or dangerous behaviors that can’t be managed in other settings
Pathways to Permanency– Children and youth who are growing
up in placement and do not have a permanent plan
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Phase 2 Target Populations
Bridge to Success and Safety– Youth with complex needs who are
mandated to out of home placement in the juvenile justice system but are currently in detention
Reconnecting and Reconstructing– Sexually exploited girls who are
unable to stay in placement using current approaches
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How Many Youth?
All youth/children in this pilot must be:– A dependent or ward of the court
described in section 300 or 602 of the Welfare & Institutions Code and/or,
– Receiving services under AB 3632
Family Reattachment – 100 Pathways to Permanence – 600
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Criteria for Determining Target Population
Statistical case review – CWS/CMS
Individual case review – look for common characteristics
Optimal volume to sustain population?
Is there an existing cross-system partnership?
Can a program be regionally implemented?
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Common Characteristics
Age and Gender– Male – 12-16 years old
Ethnicity– African American
Average length of placement in group care– More than 2 years
Average number of placements– 5-7– Out of county
Minimal family and community connections
Multiple psychotropic medications Multiple assessments/evaluations
for treatment– Diagnosis?
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Next Steps
RFQ response Intake & referral process Project entry/exit/capacity Training
– Providers– Staff– Community
Measure results
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Residentially Based Services Proposed Funding Streams
BAY AREA CONSORTIUM
Presented by: Liz Crudo, San Fransisco County and Ellen Bucci, San Mateo
County
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Objective
• To provide an overview of potential funding streams;
• Discuss potential funding model;
• Next steps.
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Current funding sources
• Residential stay AFDC-FC Medi-cal / EPSDT
• Community stayAB 163 Wraparound FundingMedi-cal / EPSDT
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Potential Funding Streams
• EPSDT– Case mgmt– Medication support– Therapy
• SB 163 Wraparound
• AFDC Residential Rate– Monthly bed rate board and care– In house stabilization
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Potential Funding Streams (con’t)
• Other Wrap Dollars– New or unused slots– Wrap Savings
• Mental Health Services Act (MHSA)
• PSSF / CAPIT / STOP / TANF/Family Preservation/TCM/CALWORKS
• County General Fund
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New Funding Model Assumptions
No new moneys;
Impact of State budget;
Providers will need to be Medi-cal certified for billing and leverage purposes;
Will require waivers and utilization of multiple funding streams;
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New Funding Model Assumptions (con’t)
Need to build service model first, then funding structure (What do we want to achieve, rather than how much money do we have?);
Providers need to be WRAP eligible; and
Counties will need to apply for additional WRAP slots.
Counties would each need to contract with the provider for Medi-cal
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New Funding Model Questions to be answered
• Service Model needs to be discussed and explored with Providers (Providers have knowledge re:making funding work);
• Need cost information from Providers; – Cost per individual youth will vary greatly?– Price Point? (average fair price)– Existing staff to be utilized or new staff?– How will youth without Medi-Cal be served?
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Next Steps
• Complete RFQ;
• Hold discussions with providers;
• Create funding model.
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Los Angeles CountyProposed RBS
Demonstration ProjectRBS Forum
Sacramento, CA
September 4/5, 2008
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Mission, Vision, Collaboration
Sept., 4/5, 2008 Los Angeles County RBS Demonstration 38
MissionThe Los Angeles RBS Demonstration will transform intensive mental health services within the child welfare system to empower families and achieve permanency for youth.
Vision The creation of a strength-based, family-centered, needs-driven system of care that transforms group homes from long-term placements to short-term interventions, which are not place-based, which provide for seamless transitions to continuing care, and which support the safety and permanency needs of youth and their families
LA RBS CollaborativeIn November of 2007, the RBS Collaborative design group was formed and is composed of county, provider and community stakeholders.
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LAC Group Home Trend Data
LA DCFS Children in Group Homes Trend 2004-Present
0
500
1000
1500
2000
Apr-05
Jul-05
Oct-05
Jan-06
Apr-06
Jul-06
Oct-06
Jan-07
Apr-07
Jul-07
Oct-07
Jan-08
Apr-08
Jul-08
Child
ren
RCL 14 RCL 12 RCL 11 RCL 10 RCL 9 RCL 8 RCL 7 RCL 6 RCL 5 RCL 4
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Target Population
• Children in or approved for RCL 12 or 14 placements– CANS will be the assessment tool
• Approximately 200 DCFS children will be served– Over 24 mos– Using up to 64 RCL 12 or 14 beds and 192 Wrap slots
• Average age – 15.8 years
Sept., 4/5, 2008 Los Angeles County RBS Demonstration 40
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Page - 41
Baseline Data: RCL-12 Children
Total Time in Current GH (36 mo view)
0
20
40
60
80
100
120
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
Months
0
100
200
300
400
500
600
700
800
900
# of Children x PeriodTotal # of ChildrenTrend
Chi
ld/m
o.
Tota
l Chi
ldre
n50%
90%
80%
All RCL 12 FY 2006-07 Exit Cohort Data
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Baseline Data Continued(collaborative profile applied)
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Page - 43
LOS Data Analysis
Notes:1. For RCL 12, 24 mo. analysis captures ~90% of population2. For ‘Collaborative Profile’ - 24 mo. analysis captures ~80% of
population
Total FC(mos)
Total GH(mos)
Curr. GH(mos)
All RCL 12s 62 22 10RCL 12/14 Combined 65 27 15Collaborative Profile 66 26 18
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Proposed Outcomes
Sept., 4/5, 2008 Los Angeles County RBS Demonstration 44
SAFETY• Safety in placement• Safety in home-based settings
PERMANENCY• Shortened timelines to permanency for youth• Limited, shortened length of stay in RCL 12 and 14 placements• Stability in home-based settings
WELL BEING• Family and youth satisfaction with RBS services• Family identification and connection for disconnected youth• Culturally and linguistically sensitive family involvement (visitation, participation in
and ratification of planning process, agency contact, connectedness)• Educational improvement (attendance, stability, GPA)• Socio-behavioral improvement (evidenced by CANS)
COST• Cost neutrality
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Wraparound and Group Home Enrollment (FY 2003 – 2007)
Wraparound vs. Group Home Enrollment 2003 - 2007
1096979
799
575528490406368327
175
1289134514561471
165218361873
205320532184
0
500
1000
1500
2000
2500
Apr'03
May'03
Dec'03
May'04
J uly'04
Dec'04
J an'05
May'05
J uly'05
Dec'05
J an'06
May'06
Dec'06
May'07
J une'07
Aug'07
Oct'07
Wraparound Enrollment Group Home Enrollment (RCL 4 - 14)
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Cornerstone Innovations• Wraparound-based Child and Family Teams
during residential tx.
• Family finding, engagement, preparation and support during residential tx.
• Residential therapeutic milieu influenced by Wraparound principles
• Shared risk/benefit between County and providers
Sept., 4/5, 2008 Los Angeles County RBS Demonstration 46
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System Design
Sept., 4/5, 2008 Los Angeles County RBS Demonstration 47
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Proposed Funding Model• Augmented residential rate for facility based services
– RCL-12 = $5,891+ $2,300 RBS rate– RCL-14 = $6,694 + $2,300 RBS rate– Modeled at 9 months
• RBS Rate covers– Family finding, engagement, preparation and support– Child and Family Team– Flex funds
• LAC Wrap rate for community based services ($4,184 excluding placement costs)
• Risk pool– Could possibly be used for
• Extended LOS• Respite• Unanticipated costs• Placement costs during Wraparound
– $1,000 set aside per month per child for 1st 12 months of care
• Cost reconciliation – Either annually or semi-annually– Share risk and benefit
Sept., 4/5, 2008 Los Angeles County RBS Demonstration 48
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Potential Waiver Requests
• RCL and related point systems• No new placement agreement for respite
Sept., 4/5, 2008 Los Angeles County RBS Demonstration 49
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Current Status
• Request for interest letter to be issued mid-Sept.
• Provider selection by end of Sept.
• Contract negotiations to follow
Sept., 4/5, 2008 Los Angeles County RBS Demonstration 50
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Concerns/Issues/Requests for Help
• Cost neutrality calculation
• Interaction with Title IV-E Waiver
• Administration and claiming processes
• CCL implications
Sept., 4/5, 2008 Los Angeles County RBS Demonstration 51
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Sacramento County RBS Reform
Collaborative Reform in Progress
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Who are we?
County Agencies (CW, MH, Probation, DHA, Education)
Group Home Providers Parents Youth
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Our Vision, Mission, Values & Guiding Principles
“Roots to Grow, Wings to Fly”
Vision Reconnecting children, families & community
Mission Insure that all children and youth who receive residential services
are ultimately able to connect or reconnect with family, school & community so they can achieve productive adult life outcomes
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Statement of Shared Principles & Core Values
RBS reform is critical to improving the ability of children and families in Sacramento County to get the right services, at the right time and the right location.
Residentially Based Services should:
√Demonstrate respect for the culture, individuality and humanity of children, youth and families
√Provide and use thorough assessments to drive services
that are tailored to individual, youth and families
√Help children and youth in placement quickly return to and
remain safe within their families, successful in their schools and integrate into their communities
√Hold all providers and systems accountable for actions and
outcomes
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RBS Outcome Goals Increased % of children and youth discharged to
permanency Improved placement stability for children and
youth in group care Decreased % of children and youth re-entering
after discharge from group care Shortened length of career stay for children and
youth in group care Decreased % of children and youth placed in out
of county group care
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Target Population & Start-up Criteria
Initial Target Population
CW, MH, Prob youth ages 12-16 Assessed to need or already in RCL 12 or above 30 slots/beds to start Child Welfare 12 Probation 12 Mental Health 6 2-3 providers w/plan to increase number of youth &
providers annually
Referral Criteria
Presents safety issues for self or others that requires 24 hours supervision and needs cannot be met in family setting or lower level of care
Not currently receiving Wrap Unmet mental health needs present and likely to
continue for extended time without RBS, and for Initial Start-Up Only Current connection w/family or NFREM
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Service Inputs→ Should produce these outputs→ Which should result in these improved outcomes:
Thorough assessment Good fit: right level, right services Placement stability, and matching shorter LOS Parent and youth Active participation in case Increased ownership engagement planning process w/case plan: process placement stability: shorter LOS Intensive short-term Stabilization, safety; improved Continuity of family residential stabilization ability to cope; pro-social skills; and community and assessment pro-social competence connection: increase
in # of kids discharged to perm
On-going family in-home Improved family functioning Kids have needs met services at home; decrease # children returning to OH care
Our Theory of Change
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Our Theory of ChangeService Inputs→ Should produce these outputs→ Which should result in these improved outcomes: Individual child and family Improved family functioning: “right Decrease in psych. Services in or out of services, right time, right place” hospitalizations and Of placement across continuum of care and juvenile hall episodes; relationships decreased re-entry into CWS or Juv Justice Educational engagement Educational continuity Academic achievement, and enrichment svcs placement and enrichment svcs stability Comprehensive care Integrated services delivered All coordination under a single case plan Non-traditional support Informal support network Decrease # children services strengthened; culturally re-entering care appropriate services delivered Intensive permanency Reconnection/Strengthening All services family ties, or finding alt permanency
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The RBS Service Array
1. Comprehensive Care Coordination
2. Family Engagement & Empowerment
3. Intensive Short-term Residential Stabilization &
Assessment
4. Intensive Permanency
5. Ongoing Family Support
6. Education Engagement & Enrichment
7. Individualized child, Youth & Family Behavioral
8. Non-traditional Support & Assistance
9. Other Innovative Options & Approaches
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The RBS Program Design
Service Array→ Service Options→ Program Model
Assessment & MatchingPlan of CareFacility Based ServicesCommunity Based ServicesPermanency Services
What’s new that will make the difference?
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Assessment & Matching
Enhanced TDM Use of CANS as standardized assessment tool Child, youth & family participation Includes placement matching Provider presence Begins resource management process
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Child/youth enrolled in RBS, not “placed” “CFT like” Team to develop and coordinate
plan of care Facilitated by RBS provider…Fred
√ Facilitate√ Reunify√ Engage√ Discharge
Plan updates at 30 day & quarterly intervals Continues after residential discharge Cross system collaboration
Plan of Care
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Facility Based Services
Family membership in facility treatment team Integrated facility & community based staff for continuity of
connections, relationships, service delivery Individualized treatment Recruitment & retention of talented staff Flexible services that promote & provide for individualized interest Enrichment opportunities that anchor child in community and family Normalization w/safety contingencies Alignment of county caseworker with residential staff Active participation of caseworkers in CFT
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Permanency Services
No “old step down”, only step toward permanency
Strengthening and developing child/youth’s ties to community
Finding, developing & supporting family connections
Build knowledge, skill & expertise of county and provider RBS staff
Youth advocacy
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Coordinated by CFT Blend of parallel and aftercare Family & youth focused Comprehensive
-treatment
-respite
-educational
-recreational
Community Based Services
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Lead Agency Model
Authorization& Resource
Mgt.
ProviderFacilitated
CFTPlan of Care
Integrated Arc of Care
Full Array ofServices
TDMDischargefrom RBS
County Worker Identifies Need for Group Care
Enhanced
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Partnership Roles & Responsibilities Collaborative Process Staffing Model QA Mechanism Preliminary Training Plan Provider Selection for Next Steps...
Operational Design
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Total Cost of Care and outcome components: All clients who have left care during 2006 and 2007 From RCL 12-14 Placed by Child Welfare, Mental Health, or Probation Federal and Non-federal (to be utilized to estimate correct ratio of FED : NONFED
AFDC Costs) Dollar totals are for each time span of placement during these 2 years With Lifetime cost listed as an additional column WRAP payments are also listed and are not included in the Lifetime Cost Mental Health Treatment Costs, EPSDT and/or 26.5 Non-AFDC Costs for out of state placements and hospitalization Permanency Outcomes data Age of Clients Client Gender Distance of Provider from Sacramento Metropolitan Statistical Area Only consider Clients with Group Home placements of 90 days or longer
Identifying Necessary Data Elements
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Multiple Databases contain relevant information Requires collaboration across DHA, County
CMS/CWS Workers, Children’s Mental Health Manually combining information from databases Multiple refinements of Data Requests from each
database Large data set of approx. 850 clients
Challenges
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Average Placement Cost* $133,401 in AFDC Payments + WRAP
$17,471 = $150,872** Fed/Non-Fed 71.5% / 28.5% Male/Female 60% / 40% Average Age 16.4 years
*Does not include additional payments for Mental Health, 26.5, Out of state, and/or Hospitalization.
**Preliminary figures, rough, not yet reliable!
Results
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Service Areas Responsibilities to carry out components of
each service Expected Funding Sources for each
component within the service
Provider Estimates of RBS Services
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1. Comprehensive Care Coordination 2. Family Engagement & Empowerment 3. Intensive Short-term Residential Stabilization &
Assessment 4. Intensive Permanency 5. Ongoing Family Support 6. Education Engagement & Enrichment 7. Individualized child, Youth & Family Behavioral 8. Non-traditional Support & Assistance 9. Other Innovative Options & Approaches
The RBS Service Array
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Funding Components of the RBS RateProvider Cost 156,489
Monthly 8,694
EPSDT 2,906 33.4%
AFDC 3,645 41.9%
AFDC/Flex 2,142 24.6%
8,694
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Next Steps
Continue to Refine reliability of Data Adjust Funding Shares as necessary Determine Payment Strategy Determine Risk Pool Strategy
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Regulatory Interpretation-”Strict Liability” be replaced with a “Standards of Care” or “Prudent Parent” standard-AWOL “violations” be replaced with “Standards of Care for AWOL Behavior”
Licensed Capacity- 84068.1(c)(1), 84088(a)1-Request waiver for regs to accommodate emergency placements when not in conflict with fire clearance or use permits
Facility-84065.2(d),(e)1&2-Personnel Duties-Request flexible use of staff-Request waiver to be able use logical and natural consequences
as determined by the treatment team Training Requirements- 84065(3)
-Allow expansion of approved trainings to prepare staff to work between residential, community and home
Regulatory Waiver Overview
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Fiscal Waivers
Rate Classification Level System (RCL) Section 11.402.000-Waive entire RCL system to be replaced by provisional rate with cost
settlement -Provides more flexible and efficient use of FC $$-Costs to be reported on semi-annual basis -Annual audit to follow A122 and 133 auditing standards
AFDC-FC State Share Waiver-Waiver to create funding stream specific to RBS
community based services for aftercare and parallel services-To be used for non EPSDT billable services throughout continuum of care
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What We’ve Learned & Where We’re Going
Collaboration is slow, but the way to go Vision, Mission & Values were key to moving
forward It’s hard to crawl outside the box Program and funding Model development is a
dance
Next Steps Close gaps & finalize work to date Develop Operational & Evaluation Model Meet 10/3 deliverable deadline!!!
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Presenter Contact Information
Jim Martin Geri WilsonExecutive Director Sacramento County
Martin’s Achievement Place RBS Reform Project Coord.(916) 338-1001 (916) 875-2-2023(916) 338-1044 fax (916) 599-3828 [email protected] [email protected]
Dan PetrieSr. Program DirectorMilhous Children’s Services(916) 265-9057(916) 215-9057 [email protected]
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San Bernardino CountyRBS Demonstration
RBS ForumSacramento, CA
September 4/5, 2008
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Overall ApproachTransform the child and family experience for children placed in RCL-14, out of state, and in psychiatric hospitals so the
•Voice and choice for the child and family is present
•Continuity of care exists throughout the trajectory of care (no hand-offs, no drop-offs)
•Continuum of care is planned, managed and reviewed regularly
•Outcome focus of the demonstration is achieved
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County, Provider, and Community Partnership
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Mission, Vision, ValuesMission
Working together to safely build and sustain positive, successful family connections and children’s futures.
VisionThe transformed system will provide resources specifically designed to facilitate
the ongoing movement of children and youth who have complex emotional and behavioral needs toward more enduring and positive connection or reconnection with their families, schools and communities. The transformed system will create effective partnership and collaboration across systems in the interest of better outcomes for those youth and their families.
ValuesStability, permanency and safety focus
FlexibilityIntegration across systems
Continuous planning and evaluation across the arc of enrollmentContinuity of care
Partnership and engagement
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Family Driven - Youth Guided
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Cornerstone Innovations• Family Passport
• Care Coordination Team
• Wrap approach throughout trajectory of care
• ITFC-like foster care consistent with RBS
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A Continuum of Care with No Handoffs
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Primary Outcome Focus
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1. Reduced Length of Stay
2. Reduced level of care including out of state
3. Reduced Hospitalizations
4. Reduced AWOL incidents
5. Improved Permanency
a. Stable placementb. Increased pro-social behaviorc. Life long connections
Stakeholder-Driven
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Baseline Sample Demographics*
Frequency %
Male 15 39%
Female 23 61%
Black 11 29%
Latino 6 16%
Native American 1 3%
White 20 53%
* Sample of 38 youth who had at least one RCL-14 placement day in 2007
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Outcome Baselines
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PERMANENCY BLAvg. current GH stay 7.7 mos2 in foster home, LOS 0.9 mos1 at home, length of stay 3.8 mosAvg. Time in Foster Care 6.2 yrsAvg. # of prior placements 3.0Reentry in to foster care tbdExits to permanency tbd#of supportive connections tbd
WELL BEING: BL
Avg. time in GH care 24.5 mos
Avg. # days AWOL 24.8 daysAvg. # of AWOL episodes 3.2Avg. # days in hospital 40.8
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Cost Baseline
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COST BL
Total cost of FC (sample) $7.5MGH Cost $5.6MOut of state costs $1.6MNon Tx foster home costs $30KFFA costs $206KOther small family homes $90K
Hospitalization cost $760K
Total 3-yr cost $8.2M
• Reflects costs over 2004 to 2007 for baseline sample• Average cost of $72,000 per yr per child
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“Rachel” - A candidate for RBS (16.8 yrs old)
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1995 - 1999 2000 - 2003 2004 2005 2006
1995-98 - six unsubstantiated abuse/neglect referrals concerning younger sister
1996 – BM incarcerated 20 months; children w/GM
1999 – 1 referral concerning all 3 children
No activity
Apr – Substantiated physical abuse by step parent; removal to FFA
May-Dec 4 GH placements
Dec Home under FM (Wrap)RespiteGH #51st hospitalizationGH #6
Jan Home under FM (Wrap)School and AWOL incidentBM requests removalBack to GH #6
May AWOL from GH #6FBM and GM return to DCSGH #7, AWOLGH #4, AWOL
Jun-Sep AWOL from GH #4, AWOL from 2 FFA Placements, ends up w/ BF
Sep-Oct GH #8, pregnantAWOL (Las Vegas)Return by BM to temp. FFAAWOL x2, returns to GH #8
Oct-Dec AWOL in LA w/boy friend and GM
Jan Home under FM (Wrap)School and AWOL incidentBM requests removalBack to GH #6
May AWOL from GH #6FBM and GM return to DCSGH #7, AWOLGH #4, AWOL
Jun-Sep AWOL from GH #4, AWOL from 2 FFA Placements, ends up w/ BF
Sep-Oct GH #8, pregnantAWOL (Las Vegas)Return by BM to temp. FFAAWOL x2, returns to GH #8
Oct-Dec AWOL in LA w/boy friend and GM
Jan-JunStill AWOL, rape, miscarriage
Jul-OctFFA #3AWOL (Back to GM)
Oct-Dec 2nd hospitalizationConservatorship
Dec-PresentPlaced out of state (RCL- 14)
• 2 abuse/neglect referrals• 12 GH placements in 9 GHs• 5 FFA placements in 3 FFAs• 2 psych hospitalizations• 12 AWOL incidents• 2 Wrap failures• 1 rape• 2 pregnancies, 2 miscarriages
• Motivated to be with family• Maintains family contact• Searches for extended family• Stable out of state for 2 years• Engages in goal setting• Survival skills
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Designing a New System for Rachel
Rachel
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Proposed Funding Model
• “Success First Wrap” MHSA – Funds Care Coordination Team across arc of
enrollment for 12 slots
– Approximately $3,000/mo/child
• SB 163 Wrap takes over when MHSA ends
• Rate for Facility Based Services - TBD
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Potential Waiver Requests
Still under considerationWaivers need to be provider driven
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Current Status
• One provider tentatively selected with both Wrap and residential beds
• Funding streams identified and model under construction
• High level System Design complete
• Facility based service model under construction
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Concerns/Issues/Requests for Help
Models will evolve during implementation
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