Improving Child & Family Well-Being Through Creative Financing Strategies

Session X

at: Because Minds Matter: Collaborating to Strengthen Medications for Children & Youth in Foster Care

Washington DC – August 27 – 28, 2012

Presented By:

Angelo McCain, PhD

Commissioner Massachusetts Dept of Social Services

Janice DeFrances, Ed.D

Director Rhode Island Dept of Children, Youth & Families

Sheila Pires, MPA

Partner, Human Service Collaborative, DC

Bruce Kamradt, MSW

Administrator of Childrens Mental Health Services/Wraparound Milwaukee, WI

What is Wraparound Milwaukee

It is a unique “system of care” for children and adolescents with serious emotional, behavioral and mental health needs and their families designed to achieve better child and family outcomes at less cost

Serves Milwaukee County – 1 million population The program serves over 1,400 (950 avg daily

enrollment) families annually with a budget of $47 million per year

70% of youth served are under the jurisdiction of Child Welfare or Juvenile Justice

What is Wraparound Milwaukee – cont’d

Youth served are those with complex needs at immediate risk of institutional care in residential treatment facilities, psychiatric inpatient facilities or juvenile correctional facilities

Our approach is based on a set of core values and principles that put child and family well being at the center of the service systems

Elements of Wraparound

Values & Principles

How is Wraparound Milwaukee Structural & Organized

Publically operated Care Management Entity (CME) – operated by Milwaukee County Behavioral Health Division to care for SED youth regardless of the child serving system they come from and are involved with

Integrated delivery of behavioral health and supportive services across child serving systems for SED youth

Pooled funding across systems Single payor of all care, including mental health, substance abuse,

supportive services and out-of-home care minus physical care One care plan – one care coordinator Extensive service array and provider network Family directed – youth guided

How is Wraparound Milwaukee Structural & Organized – cont’d

It is type of a behavioral health carve-out under a 1915(a) contract between Milwaukee County Human Services and State Dept. of Health but is more comprehensive because it covers the delivery of services for children and families beyond what Medicaid would normally cover

While it does not directly cover physical health care costs it coordinates with the primary care physician particularly around special health conditions and use of psychotropic medication

Why was Wraparound Milwaukee Created

Overutilization of institutional placements for children in mid – 1990’s particularly residential treatment, psychiatric hospitalization and juvenile correctional placements

Poor outcomes of youth utilizing these out-of-home placements

Overuse of high-cost institutional care was causing financial problems for Milwaukee County and Medicaid

System needed better oversight, accountability and more community-based alternatives

What are Components of Wraparound

Milwaukee Care Management Model

Using a Care Management Entity (CME) model, it oversees care of all children with serious emotional and mental health needs across child serving systems

Does fiscal management of system Contracts with other child serving agencies ex.

Medicaid, Child Welfare, Juvenile Justice, etc. Provides assessment/screening of youth eligible for

enrollment Provides or contracts for care coordination services

(1:10 ratio)

What are Components of Wraparound

Milwaukee Model – cont’d

Operates 24/7 mobile crisis intervention services Creates and manages a Provider Network of 200

agencies with 60 different services Provides clinical and medical supervision of

behavioral health areas Operates a single IT system and electronic health

record (minus physical health) Conducts Quality Assurance/Quality Improvement

and Program Evaluation

Wraparound Milwaukee’s Funding Model

Creates a funding pool through various funding arrangements1. Medicaid – actuarial determined capitated rate plus fee-for-service for crisis

services

2. Child Welfare – case rate agreement covering non-medicaid provided services particularly out-of-home care costs

3. Delinquency Services – fixed annual funding based on 1995 expenditures ($8 million) plus a monthly case rate for diversions from juvenile corrections

Principle approach is to re-direct money from institutional placement expenditures to community-based care

Wraparound Milwaukee is the single payor for all services for enrolled youth, is at risk for service costs and therefore has incentive to insure most appropriate , cost effective care

Creating “win-win” Scenarios

System of Care

Child Welfare

Alternative to out-of-home care high costs/poor outcomes

Juvenile Justice

Alternative to residential & Correctional placements

Medicaid

Alternative to IP/ER-high cost

Special Education

Alternative to day treatment costs

How We Pool Funds

CHILD WELFAREFunds thru Case Rate

(Budget for InstitutionalCare for Chips Children)

JUVENILE JUSTICE(Funds Budgeted for

Residential Treatment and Juvenile Corrections Placements)

MEDICAID CAPITATION(2052per Month per Enrollee)

MENTAL HEALTH•CRISIS BILLING•HTI GRANT•HMO COMMERCIAL INSUR

WRAPAROUND MILWAUKEECARE MANAGEMENT ORGANIZATION

(CMO)47.0M

CHILD & FAMILY TEAMOR

TRANSITION TEAM

PLAN OF CAREOR

10.0M 10.0M 20.0M 7.0 M

CARECOORDINATION

OR

TRANISITIONAL SPECIALIST

PROVIDER NETWORK

210 Providers

60 Services

FUTURES PLAN

FAMILIES UNITED

$400,000

Advantages of Blended or Pooled Funding Model

Flexibility Adequacy of funding De-Categorization of funds Responsive to changing needs Lends itself to positive manage care approach – don’t

need to “ration care” De-Politicalizes allocation and awarding of funds

Outcomes for the System & Youth Served in Wraparound Milwaukee

Outcomes currently being measured include programmatic, fiscal, clinical, public safety, child permanency and consumer satisfactionProgrammatically – the average daily residential treatment population has dropped from 375 youth to 80 youth, inpatient psychiatric days from 5000 to under 500 days per yearFiscally – the averages cost for a child/family in Wraparound is under $4000 per month versus over $10,000 per month for a residential treatment placement, over $9000 per month for a correctional placement or well over $10,000 for a 7-day hospital stayClinically – children function better at home, school and in the community based on administration of nationally normed measures such as the CBCL (Achenbach) used at the time of enrollment and discharge

Outcomes for the System & Youth Served

in Wraparound Milwaukee – cont’d

Public Safety – recidivism rates for delinquents are low (15.2%) for youth in the program for at least one year and even lower (6.7%) for high risk offenders including juvenile sex offenders (this is considerably under national standards)

Child Permanence – 80% of youth achieve permanency, i.e., return to parents, relatives, adoptive resources or subsidized guardianship upon leaving Wraparound

Family Satisfaction – families surveyed upon completing Wraparound (average 18 months) gave the program a rating of 4.4 out of 5 points in terms of their perception of the progress their child made while in the program

8389

7989

7609

7247

6573

6260

5961

5678

5408

5151

4906

4673

4450

6902

4000

4500

5000

5500

6000

6500

7000

7500

8000

8500

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

RT

C R

ate

Cost of Doing Nothing

Residential Treatment Placements & Costs Without

Wraparound Milwaukee

18.419.9

22.024.1

26.629.2

32.3

35.6

38.9

Child Welfare/Juvenile Justice Expenditures for RTC without

Wraparound Milwaukee

RTC Placements

Potential Increase in RTC Placements w/o Wraparound Milwaukee

(5% growth with NO Change in LOS)

Average Daily Census of Youth In RTC’s

*Actual Number of Placements and Costs for That Year

*

43.0

*

RTC Rate Increase of 5%/year

With 5% Increase of No. of Placements

Average RTC Rate and Total ProjectedAnnual Expenditures

47.4

52.2

57.5

63.4