Services and Supports ArrayProvider NetworkNatural HelpersFinancing – Track 2 Sheila A. Pires

Human Service Collaborativesapires@aol.com

Vickie MieneNortheast Iowavickie-miene@uiowa.edu

Matt WojackIngham County, Michiganwojack@ceicmh.org

22

State and Local Realities

Growing evidence of effectiveness of home and community-based services & of system of care technologies – even for youth with

most challenging issues, e.g. youth with sex offenses, fire starting behaviors, dual diagnoses

+Potential cost savings to Medicaid, mental health, child

welfare, education, juvenile justice in HCB and SOC+

Lack of sufficient HCB service capacity +

Dollars are finite

Conclusion: Redirect spending from out of home placements with high costs and/or poor outcomes to home and community-based services and supports in a system of care

Pires, S. (2006). Primer Hands On . Washington, D.C.: Human Service Collaborative.

3

Redirection

Where are you spending resources onhigh costs and/or poor outcomes?

Residential Treatment?Group Homes?Detention?Hospital admissions/re-admissions?Too long stays in therapeutic foster care?Inappropriate psychotropic drug use?“Cookie-cutter” psychiatric and psychologicalevaluations?

4

Wraparound Milwaukee – Example of Redirection and Pooled Funds

Child WelfareFunds thru Case Rate

(Budget for InstitutionalCare for CHIPS Children)

Mental Health•Crisis Billing•Block Grant

•HMO Commercial Insurance

Medicaid Capitation(1557 per Month

per Enrollee

Juvenile Justice(Funds Budgeted for

Residential Treatment for Delinquent Youth)

Management Entity:Wraparound Milwaukee

Management Service Organization (MSO)$30M

Child and Family Teams

ProviderNetwork

240 Providers85 Services

CareCoordination

Plans of Care

9.5M 2.0M10M8.5M

Per Participant Case Rate

Family Organization$300,000

Mgt. Entity: Co. BH Div.

Wraparound Milwaukee. (2002). What are the pooled funds? Milwaukee, WI: Milwaukee County Mental Health Division, Child and Adolescent Services Branch

5

Dawn Project Cost Allocation

How Dawn Project is Funded

Example of Braided FundsDAWN Project - Indianapolis, IN

2005 CHIOCES, Inc., Indianapolis, IN

RAINBOWS

(Family Organization)

CFT and Care Coordination Structure

6

Example of “Virtual” Pooled FundsCuyahoga County (Cleveland)

FCFC $$Fast/ABC $$Residential Treatment Center $$$$Therapeutic Foster Care $$$“Unruly”/shelter care $Tapestry $$SCY $$

County Administrative

Services Organization

Neighborhood Collaboratives &Lead Provider Agency

Care CoordinationPartnerships

Community Providers and Natural Helping Networks

Reinvestment of savings

Pires, S. (2006). Primer Hands On . Washington, D.C.: Human Service Collaborative.

}

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StateEarly Intervention and Family Preservation

System of Care Grants

System of Care Oversight Committee

Child and Family Team Plan of

Care

7

KEY QUESTIONS

Expenditure and Utilization Questions:

1. Which State agencies spend dollars on BH services for children and youth?

2. How much do they spend?3. What types of dollars are spent (e.g., Fed’l., State)?4. What services are financed?5. How many children and youth use services?6. What are the characteristics of these children and youth

(e.g., by age, gender, race/ethnicity, diagnosis, region)?7. What services do they use? 8. How much service do they use?

8

Financing Strategies and Structures to Support Improved Outcomes for Children, Youth and Families

FIRST PRINCIPLE: System Design Drives Financing

Adapted from Friedman, M. (1995). Financing strategies to support improved outcomes for children. Washington, DC: Center for the Study of Social Policy.

REDEPLOYMENTUsing the money we already haveThe cost of doing nothingShifting funds from treatment to early intervention and preventionMoving across fiscal years

REFINANCINGGenerating new money by increasing federal claimsThe commitment to reinvest funds for families and childrenFoster Care and Adoption Assistance (Title IV-E)Medicaid (Title XIX)

RAISING OTHER REVENUE TO SUPPORT FAMILIES AND CHILDRENDonationsSpecial taxes and taxing districts for childrenFees & third party collections including child supportTrust funds

FINANCING STRUCTURES THAT SUPPORT GOALSSeamless services: Financial claiming invisible to families Funding pools: Breaking the lock of agency ownership of fundsFlexible Dollars: Removing the barriers to meeting the unique needs of familiesIncentives: Rewarding good practice

9

Medicaid Option Advantages Issues Example

Rehabilitation Services Option

•Flexibility to cover a broad array of services and supports provided in different settings (e.g., home, school)

•Service definitions often adult-oriented

•Federal scrutiny

•Many states

Managed Care Demos and Waivers - 1115 and 1915 (b)

•Accountability and management of cost through risk structuring/sharing

•Flexibility to cover wide range of services and populations

•Managed care not without risks/challenges

•Federal waiver process can be challenging

•Cost neutrality issues

•NM – covering MST

•AZ – covering family support, therapeutic foster care

Home and Community-Based Waivers - 1915 (c)

•Flexibility, broader coverage, waiver of income limits and comparability

•Alternative to hospital-level of care, but PRTF (i.e., residential treatment) may be issue

•Cost and management concerns limited to small number

•KS, NY, VT, IN, WI – have HCBS Waivers•AK, FL, GA, IN, KN, MD, MS, MT, SC, VA – have community alternatives to psychiatric residential treatment facilities demonstration grant

Examples of Medicaid Options States Use to Cover Evidence-Based and Promising Community-Based Practices (1)

Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

10

Medicaid Option

Advantages Issues Example

Early and Periodic Screening, Diagnosis and Treatment - EPSDT

•Broadest entitlement

•Supports holistic (PH and BH) assessments and services

•No waiver or state plan amendment requirements

•Management mechanism critical because of cost concerns

•Oriented more to physical health in practice

•RI

•PA

Targeted Case Management

•Can be targeted to high need populations

•Supports small case load focus (e.g., 1-10)

•Not sufficient without other services

•Federal attention

•VT

•NY

Administrative Case Management

•Ability to cover basic case management services to support enrollment access

•Not sufficient without other services

•NJ – covering some activities of family-run organization

Examples of Medicaid Options States Use to Cover Evidence-Based and Promising Community-Based Practices (2)

Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

11

Medicaid Option

Advantages Issues Example

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

•Avenue to eligibility to community-based services for children who meet SSI disability criteria – allows disregard of family income

•SSI criteria not easy to meet for children with SED

•Does not expand types of covered services

•Cost issues, so generally small program

•MN

•WI

Medicaid as Part of a Blended or Braided Funding Approach (without a waiver)

•Holistic, integrated (across systems) financing, supports broad array of services, natural supports and individualized care

•Involves significant restructuring

•Milwaukee Wraparound

•DAWN Project

•Massachusetts Mental Health Services Program for Youth

•New Jersey Partnership

Examples of Medicaid Options States Use to Cover Evidence-Based and Promising Community-Based Practices (3)

Pires, S. 2005. Building systems of care. Human Service Collaborative. Washington, D.C.

12

Purchasing/Contracting OptionsPre-Approved Provider Lists:+ Flexibility for system of care + Choice for families - Could disadvantage small indigenous providers- Could create overload on some providers

Risk-Based Contracts+ Flexibility for providers+ Individualized care for families - Potential for under-service- Potential for overpaying for services

Fixed Price/Service Contracts+ Predictability and stability for providers - Inflexible-families have to “fit” what is available

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

13

Capitation and Case Rate Distinctions

Capitation: Pays MCOs or providers a fixed rate per eligible user Incentive: #1: Prevent eligible users from becoming actual users (e.g., make it difficult to access services; engage in prevention)#2: Control the type and volume of services used

Case Rate: Pays MCOs or providers a fixed rate per actual userIncentive: #1: Control the type and volume of services used

Pires, S. Building systems of care: A primer. Washington, D.C.: Human Service Collaborative.

14

Risk-Based Contracting Arrangement

Pires, S. (1999). El paso county, colorado risk-based contracting arrangement. Washington, DC: Human Service Collaborative.

State-Capped Out of Home Placement Allocation

County Dept. of Human Services acts as Management Care Organization (contracting, monitoring, utilization review)

Child Welfare $$Case rate contract with CPA

BH Tx $$ matched by Medicaid. Capitation contract with BHO with risk-adjusted rates for child welfare-involved children

Joint treatment planning approved by Dept. of Human Services

Child Placement Agencies (CPA)

Responsible for full range of Child WelfareServices & ASFA (Adoption and Safe Families ACT) related outcomes

Mental Health Assessment and Service Agency (BHO)

Responsible (at risk) for full range of MH treatment services & clinical outcomes & ASO functions

Services/Supports Array, Provider Network, Natural Helpers and

Financing

Vickie MieneIowa

Iowa’s current system

Lessons Learned - Community Based Resources

• Building on existing Community Based Services is:– Empowering to the agency

providing the service– Better for youth and families

(fewer out of town trips saves gas, energy, and time)

– Creates better relationships with the service agencies and forces communication among providers and the SOC which results in less duplication of efforts.

– SOC values and principals are taught and applied on a local level, creating a common thread between service entities

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Family Team Meeting• Natural Supports identified• Agenda set by family/youth• Community supports Family Team Meeting

Concept, (providers attend and provide input, they offer to host meetings at their location)

• Families report feeling empowered and like they really had choices

• Barriers discovered during family team meetings, are taken to advisory meetings for solution focused discussion.

Crisis Intervention Services• 1-800 number for over the phone crisis talk down• 1 hour face to face response with a crisis intervention

worker• Cool down respite placement that can be utilized for 48

hours.

STEP-IN Crisis Services

• 45 day program• Intensive Family

Preservation Model• 1 hour response time• Prevent hospitalization• Utilize respite if needed

Service/Supports Array, Provider Network, Natural

Helpers and Financing “2010 CHILD MENTAL HEALTH INITIATIVE NEW COMMUNITY

TRAINING”(Issue Briefs #3, #5, #6)

Matt Wojack

Ingham County, Michigan

Any Effective System of Care for Children with Serious Emotional Disturbance is Built Upon an Outcome Oriented Home-Based Mental Health Program

--Bob Friedman

Family Empowerment• How do We support Families in Using Voice• What Do Families Need• How are Supports Organized to

Accommodate Such

Commitment to SOC Changes the WorldShift in Values

Shift in Practice

Real Data Supports real Change

Bundle of Services• Home-Based Mental Health • Wraparound Facilitation• Family Advocacy Support

Cost Monitoring Supports the Long-Term Viability of the System

“How Do you Want to Spend Your Money?”

1 Residential = 8 System of Care

Broad Examination of Cost Savings>40% reduction in JJ; $1M saved by CPS

Case Rate Model• Up to One Year of Support• Three Components• Realigning Resources

Sustaining a System of Care“We were headed in the right direction…”

“There is no going back..”

Matt Wojack, Project DirectorImpact, Ingham County System of Care Initiative

517-346-8038

wojack@ceicmh.org

www.impactsystemofcare.org