Residential Care: Another Perspective

Normer Adams, Executive Director

Georgia Association of Homes and Services for Children

March 9, 2007

Residential Care: Another Perspective

Subtitles: The Feds have the Power The Given Reason and the Real Reason Your sins will find you out. The Assault on Residential Care

The Assault on Residential Care

1980 – AACWA- Adoptive Assistance and Child Welfare Act mandated the “least restrictive setting” and “reasonable efforts” made to reunite with families. – System driven by failure– Rigid Service system – Misunderstanding of Residential Care– Unrealistic Expectations of families

The Assault on Residential Care

Child and Family Services Review by HHS– Premiums on shorten lengths of stays– Rigid expectations of families– Residential Care is “care of last resort” regardless

of appropriateness of care

The Assault on Residential Care

Centers for Medicare and Medicaid Services– Balanced Budget Act of 1997 and 2001– Driven by Budget Reform– Escalating Costs

The Georgia Perspective

The Rumors Spread Georgia Hit Early by CMS Colorado First, Georgia Second by 6 months 30 States Targeted S.C. is ID’ed What are the rumors What do you want clarified?

The Georgia Perspective

Changes in Residential Care In 2000 5% foster children in Privatized Care In 2000 9% were classified as in Therapeutic Care

In 2006 50% of foster children in Privatized Care In 2006 28% were classified as in Therapeutic Care

In 2000 budget for residential care = $100 million In 2006 budget for residential care = $300 million

Changes in Georgia

Increased Capacity 50% increase in group home capacity in 3

years– From 2000 beds to 3000 beds

600 % in foster care capacity in 3 years– From 400 beds to 2400 beds

Tripling of the budget– From $100 million to $300 million

The Georgia Perspective

Funding Streams– In 2000 – 70% state dollars– In 2006 – 50% state dollars

Shift was made to Medicaid Funding in 2002 Rehab Option Used Georgia was late to “game” of using Medicaid

– SC used as a model.

Georgia Timeline

Year 2000– Budget Office talked of moving more to Rehab

Option for foster care. – Governor in hit hard in media about care of foster

children.– Governor forms “Action Committee for Safe

Children”– Need to address escalating treatment costs in

foster children.

Georgia Timeline

Year 2002 Georgia pilots Level of Care system of services 6 levels of services in both foster care and

congregate care

Per Diems congregate care range from $80 to $320 Foster care range from $34 to $135 Medicaid was proposed to pay for per diems

Georgia Timeline

Year 2003 New Republican Governor A “foster care” Governor Proposes $200 million in new dollars for foster care. Half secured through Medicaid Reimbursement State billed Medicaid for the “treatment services” to

foster children.

The Web We Did Weave

All children in private care had a diagnosis. Level of Care became synonymous with

privatized care. Level of Care was “therapeutic services.” Openly acknowledged a “gaming of system.”

(no one knew who was benefiting.)

From Bad to Worse

Change of Administrations New Governor New Commissioner of DHR New Commissioner of DCH New State Child Welfare Director Most from out of Georgia (“ya’ll are NOT from

around here, are ya?”)

From Bad to Worse

Institutional Knowledge Lost– No history of community stakeholders– No history of funding strategies– No history of institutional processes

Someone forgot to file a Medicaid Plan

Medicaid 101

Title XIX of the Social Security Act in 1965 to provide medical assistance to the poor.

Match Program – State and Federal participation

Administered by an State Medicaid Agency Required to have an approved plan Required to comply with plan

Medicaid 101

Each State is to provide monitoring for efficiency, economy and quality of care.

GAO Report – June 2005

GAO reviewed contingency-fee consultants in the 2 states, Georgia and Massachusetts

From these and other projects, for state fiscal years 2000 through 2004, Georgia obtained an estimated $1.5 billion in additional federal reimbursements

Georgia Paid consultants $82 million

First Signs of Trouble

GAO Report – June 2005 Rumors about problems with Medicaid

circulated fall 2005 Announcement in March 2006 problems with

Medicaid and implementation of the “debundling of services”. Some called it “debuggling.”

CMS Findings

All Medicaid payments will be withheld because of the following:

No Medicaid Plan No Prior Approval of Services No Oversight of Service provision Contracting of providers through the Child

Welfare Agency

Other findings

Cost shifting of child welfare expenditures to Medicaid

No proof of medical necessity Some facilities were more than 16 beds and

billed as primary in the treatment of mental disease (IMD – Institutions of Mental Disease)

Corrective Action Required by CMS

Actual Services must be documented Services provided must be an approved Medicaid

Service Clients must have freedom of choice for services Must have an approved State Plan Providers must be enrolled through the Medicaid

agency Systemic changes are demanded

Georgia’s Plan

We have “de-bundled” No more bundling of services paid for by per diem. No more residential treatment except our specialized

psychiatric residential treatment facilities which are licensed as hospitals. (PRTF)

– Unlawful– “Gaming the System”

The New System

Room and Board and Watchful Oversight (RBWO)– Three levels of care – Basic, additional oversight

and Intensive Oversight– Non therapeutic– Premium services rewarded

Therapy by Therapist

Mental Health Agencies approved to be mental health service providers

Professionals approved to be providers All treatment will be provided through these

providers 16 providers have made application to be

providers.

Mental Health Division

Our mental health division will approve providers and direct service provision for all mental health and behavioral health services.

Audited through a “care management organization” (CMO)

Paid for by our Medicaid Department

Public Health Division

Public Health Division will do all prevention work such as family support, preservation and abuse and neglect prevention.

Foster Care Division

They will provide all child protection services and investigations.

They will provide all placement services and contracting of placement services.

Future of Residential Care

Order of Preference for placement (if appropriate) will not be going away.

Family Relative Care Foster Care Congregate Facility

Future of Residential Care

More Home and Community based services More family and relative care Less Money Less Federal Participation

Impact on Association

More Competition, more conflict Role as prophet versus advocate. Killing the messenger. Proactive versus Reactive Collaboration with State is a must

The Visionary Future

Best Practice for Children and their Families? Creating a Funding Vision. How to implement a vision when there is not

funding in place. Role of the Association

Questions and Comments