Services and Supports Array

Provider Network

Natural Helpers

FinancingSheila A. PiresHuman Service Collaborative

Lisa ConlanParent Support Network of Rhode Island

Carrie JohnsonUnited American Indian Involvement

Michelle ZabelUniversity of Maryland

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Types of Medicaid Services in Systems of Care

• Assessment and diagnosis

• Outpatient psychotherapy

• Medical management

• Home-based services

• Day treatment/partial hospitalization

• Crisis services – mobile & residential

• Behavioral aide services

• Behavioral management skills training

• Therapeutic foster care

• Therapeutic group homes

• Inpatient hospital services

• Case management services

• School-based services

• Respite services

• Wraparound

• Family peer support/education

• Youth peer support

• Transportation

• Mental health consultation

• Early intervention and prevention services

• Supported independent living

• Residential treatment centers

Stroul, B.A., Pires, S.A., Armstrong, M.I. (2001). Health care reform tracking project: Tracking state managed care reforms as they affect children and adolescents with behavioral health disorders and their families-2000 State Survey. Tampa: University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health, Department of Child and Family Studies, Division of State and Local Support.

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Example: Broad Service Array - Dawn Services & Supports

Behavioral Health•Behavior management•Crisis intervention•Day treatment•Evaluation•Family assessment•Family preservation•Family therapy•Group therapy•Individual therapy•Parenting/family skills training•Substance abuse therapy, individual and group•Special therapy

Placement•Acute hospitalization•Foster care•Therapeutic foster care•Group home care•Relative placement•Residential treatment•Shelter care•Crisis residential•Supported independent living

Psychiatric•Assessment•Medication follow-up/psychiatric review•Nursing services

Mentor•Community case management/case aide•Clinical mentor•Educational mentor•Life coach/independent living skills mentor•Parent and family mentor•Recreational/social mentor•Supported work environment•Tutor•Community supervision

Respite•Crisis respite•Planned respite•Residential respite

Service Coordination•Case management•Service coordination•Intensive case management

Other•Camp•Team meeting•Consultation with other professionals•Guardian ad litem•Transportation•Interpretive services

Discretionary•Activities•Automobile repair•Childcare/supervision•Clothing•Educational expenses•Furnishings/appliances•Housing (rent, security deposits)•Medical•Monitoring equipment•Paid roommate•Supplies/groceries•Utilities•Incentive money

2005 CHIOCES, Inc., Indianapolis, IN

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Service Array Focused on a Total Population

Family Support Services

Youth Development Program/Activities

Coordinated Intake Assessment & Treatment Planning

Service Coordination Intensive Care

Management Clinical Services

Pires, S. & Isaacs, M. (1996, May) Service delivery and systems reform. [Training module for Annie E. Casey Foundation Urban Mental Health Initiative Training of Trainers Conference]. Washington, DC: Human Service Collaborative.

Core Services Prevention Early Intervention Intensive Services

Universal Targeted

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Evidence-Based Practices

Pires, S. (2002). Building systems of care: A primer. Washington, D.C.: Human Service Collaborative. Examples - Source: Burns & Hoagwood. 2002. Community treatment for youth: Evidence-based interventions for severe emotional and behavioral disorders. Oxford University Press and State of New Jersey BH Partnership (www.njkidsoc.org)

Show evidence of effectiveness through carefully controlled scientific studies, including random clinical trials. For example, Multisystemic Therapy, Functional Family Therapy

Promising Approaches or Practice-Based Evidence

Show evidence of effectiveness through experience of key stakeholders (e.g., families, youth, providers, administrators) and outcomes data. For example, Wraparound, MobileResponse and Stabilization, Family Peer Support

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Effectiveness Research(Barbara Burns’ Research at Duke University)

• Most evidence of efficacy: Intensive case management, in-home services, therapeutic foster care

• Less evidence (because not much research done): Crisis services, respite, mentoring, family education and support

• Least evidence (and lots of research): Inpatient, residential treatment, therapeutic group home

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

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Examples of What You Don’t See Listed as Evidence-Based Practice

(though they may be standard practice)

• Traditional office-based “talk” therapy• Residential Treatment• Group Homes• Day Treatment_______________________________________________

Examples of Potentially Harmful Programs and Effective Alternatives in Dodge, K., Dishion, T., & Lansford, J. (2006). “Deviant Peer Influences in Intervention and Public Policy for Youth,” Social Policy Report, Vol. XX, No. 1, January 2006. Youth Today: The Newspaper on Youth Work, Vol. 15, No. 7.

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

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Implications for How RTCs are Utilized

• Movement away from “placement” orientation and long lengths of stay

• Residential as part of an integrated continuum, connected to community

• Shared decision making with families/youth and other providers and agencies

• Individualized treatment approaches through a child and family team process

• Trauma-informed care

For more information, go to Building Bridges Initiative:1) www.systemsofcare.samsha.gov2) Click on Hot Topics3) Click on Issues in Residential Treatment

Data Trends #127, February 2006,University of South Florida.

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Characteristics of Effective Provider Networks

• Responsive to the population that is the focus of the system of care.

• Encompass both clinical treatment service providers and natural, social support resources, such as mentors and respite workers.

• Include both traditional and non traditional, indigenous providers.

• Include culturally and linguistically diverse providers.

• Include families and youth as providers of services and supports.

• Are flexible, structured in a way that allows for additions/deletions.

• Are accountable, structured to serve the system of care.

• Have a commitment to evidence-based and promising practices.

• Encompass choice for families and youth.

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

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The Role of Natural Helpers

•Emotional support; moral & spiritual guidance

•System navigation

•Concrete help & advocacy

•Decrease social isolation

•Community navigation

•Resource acquisition & education

•Greater understanding of intervention or support strategies

•Create Time Banks

Lazear, K., (2003) “Primer Hands On”; A skill building curriculum. Washington, D.C.: Human Service Collaborative.

Natural Helpers are…•Family and friends

•Neighbors•Volunteers

•Individuals in the community, e.g. mail carrier, minister,

storekeeper, etc. •People with similar experiences

•Faith-based organizations

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Examples of Sources of Funding for Children/ Youth with Behavioral Health Needs in the Public Sector

Pires, S. (1995). Examples of sources of behavioral health funding for children & families in the public sector. Washington, DC: Human Service Collaborative.

Medicaid• Medicaid In-Patient• Medicaid Outpatient• Medicaid

Rehabilitation Services Option

• Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT)

• Targeted Case Management

• Medicaid Waivers• TEFRA Option

Substance Abuse• SA General Revenue• SA Medicaid Match• SA Block Grant

Juvenile Justice• JJ General Revenue• JJ Medicaid Match• JJ Federal Grants

Mental Health• MH General Revenue• MH Medicaid Match• MH Block Grant

Child Welfare• CW General Revenue• CW Medicaid Match• IV-E (Foster Care and

Adoption Assistance)• IV-B (Child Welfare

Services)• Family

Preservation/Family Support

Education• ED General Revenue• ED Medicaid Match• Student Services

Other• WAGES• Children’s Medical

Services/Title V– Maternal and Child Health

• Mental Retardation/ Developmental Disabilities

• Title XXI-State Children’s Health Insurance Program (SCHIP)

• Vocational Rehabilitation

• Supplemental Security Income (SSI)

• Local Funds

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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

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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?

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Wraparound Milwaukee – Example of Redirection

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

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Examples of Refinancing

Milwaukee County, WI Schools and child welfare contributed $450,000 each to expand mobile response and stabilization services(prevent placement disruptions in child welfare, prevent school expulsions) Is a Medicaid-billable service; contributions fromschools and child welfare generate $180,00 to theschool contribution and $200,000 to child welfare’s inFederal Medicaid match dollars

Cuyahoga County, OHCross-walked 93 wraparound skill sets to Medicaidbilling categories

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Raising New Revenue

•Prop 63 in California (1% income tax on millionaires)

•Spokane Co., WA – 0.1% sales tax for mental health

•Jackson Co., KN – 1.3% per $100 property tax formental health

•Florida counties – children’s trust funds

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Creating “Win-Win” Scenarios

System of Care

Child Welfare

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

Juvenile Justice

Alternative to detention-high cost/poor outcomes

Medicaid

Alternative to IP/ER-high cost

Special Education

Alternative to out-of-schoolplacements – high cost

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

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The Cost of Doing Nothing

If Milwaukee County had done nothing: the $18m.spent by child welfare ten years ago on residentialtreatment would be $48m. today

Project Bloom “Cost of Failure Study” – Early childhoodservices at an average cost per child of $987/year save$5,693/year in special education

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The Cost of Doing Nothing:Racial & Ethnic Disparities/Disproportionality

“…youths of color were less likely to receive outpatient therapy…and more likely to receiveresidential services.” (Source: McMillen, J., Scott, L.et. al. Use of Mental Health Services Among Older Youths In Foster Care. 2004.Psychiatric Services 55:811-817. American Psychiatric Association)

“The study finds greater use of residential treatmentcenters by black persons and Hispanic persons thatis attributable in part to (public sector) managed care”(Source: Snowden, L., Cuellar, E. & Libby, A. Minority Youth in Foster Care: Managed Care and Access to Mental Health Treatment. 2003. Med Care. 41(2): 264-74). University of California Berkley)

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Strategic Financing Analysis1) Identify state and local agencies that spend dollars on children’s behavioral health services/supports.

- how much each agency is spending

- types of dollars being spent (e.g., federal, state, local, Tribal, non-governmental)

2) Identify resources that are untapped or under-utilized (e.g., Medicaid).

3) Identify utilization patterns and expenditures associated with high costs/poor outcomes, and strategies for re-direction.

4) Identify disparities and disproportionality in access to services/supports, and strategies to address.

5) Identify the funding structures that will best support the system design (e.g., blended or braided funding; risk-based financing; purchasing collaboratives).

6) Identify short and long term financing strategies (e.g., Federal revenue maximization; re-direction from restrictive levels of care; waiver; performance incentives; legislative proposal; taxpayer referendum, etc.).

Pires, S. 2006. Human Service Collaborative. Washington, D.C.

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Where Families, Youth and Family and Youth Organizations Fit Into the Service Array

As technical assistance providers & consultants

Training

Evaluation

Research

Support

Outreach/Dissemination

As direct service providers

Family Liaisons

Care Coordinators

Family Educators

Specific Program Managers (respite, etc)

Youth Peer MentorsWells, C. (2004). “Primer Hands On” for Family Organizations. Human Service Collaborative: Washington, D.C.

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Rhode Island Time Bank Initiative

• TimeBank Coordinator

• TimeBank Ambassadors

• Community Outreach

• Exchanges

• Special Projects

• Database

• Advisory Board

• Website

Time Bank Core Values: Assets-Redefining Work-Reciprocity-Community-Respect

Conlan (2007). Parent Support Network of Rhode Island Infrastructure and Primary Funding Sources.

Family Organization Sustainability Strategies

• Increase public awareness and acceptance of your organization and/or initiative.

• Develop a fund development plan for sustainability.

• Learn about all the different potential funding sources that could support your mission and family involvement work.

• Build relationships and trust with community and state agency partners and other potential funders.

• Develop a base of knowledge and evaluative results that supports your family involvement efforts in meeting the needs of children, youth, families, community and partners.

Example - Family Involvement CenterPhoenix, AZ

Contract with State Behavioral Health Agency

Medicaid managed care “administrative functions” contract

Medicaid managed care contract as provider in network

Contract with State child welfare agency

Financed initially by foundation grant; nowfinanced by State general revenue (MH), tobacco settlement,federal MH block grant, federal discretionary grant, Medicaidbillable services, and child welfare (GR and IV-E waiver)

United American Indian Involvement, Inc

Seven Generations Child and Family Services

Los Angeles

Carrie L. Johnson

Service Support Arrays and Financing

Seven Generations System of Care

DMH-Medical

Native Pathways DV/SA

Native Pathways CHAT

Family Support

Family Pres

SOC Therapists

Wellness

Center

Clubhouse

Health Project

Suicide Prevention

Ah No Ven

Central High School

DCFS

DMH

Schools

Probation

TaniffOther Indian Agencies/Programs

Head Start

Child and Family

SAIF

Natural Helpers

Youth and Parent mentors

Traditional and Spiritual Advisors

Service/Supports and Financing • Developing our Logic Model• Establishing our Services/Supports• What more is needed?• Increase collaborations• Increase Financing- with a focus on Sustainability• Continually reviewing our Cultural Competency

plan- Training on Cultural Competency to other service providers and staff, youth and family

Presented by Michelle Zabel, MSSDirector, Maryland Child & Adolescent Innovations Institute, Mental

Health Institute & Juvenile Justice InstituteDivision of Child & Adolescent Psychiatry, School of Medicine,

University of Maryland, Baltimore

Service/Support Array, Provider Network, Natural Helpers and

Financing

Continuum of Opportunities, Supports, and Care

There is a need for the Children’s Cabinet to agree on a continuum of opportunities,

supports, and care, including evidence-based and promising practices, and work toward

ensuring that appropriate levels of services and supports are available to every jurisdiction

and community to meet their specific population needs, with the intent of improving

outcomes and reducing out-of-home placements.

Recommendation 1: The Children’s Cabinet is committed to the creation of a full community-based continuum of opportunities, supports, and care that is developed in partnership with local jurisdictions, families and the provider community to meet the specific, individualized needs of children and families. The Children’s Cabinet should prioritize efforts to safely and effectively serve children in their own homes by expanding the continuum of services. These efforts should include increased diversity, quality, and accessibility of in-home services with an emphasis on reunifying children with their families at the earliest possible time. Services should be culturally competent and responsive, and children should receive all supports to which they are entitled.

Continuum of Opportunities, Supports, and Care

Recommendation 2: The Children’s Cabinet should work collaboratively to serve children

who are in an out-of-home placement in their home schools and communities more

effectively with fewer placement disruptions resulting in better permanency outcomes for

children and families.

Recommendation 3: There should be a commitment to diverting youth from detention

and commitment within the juvenile justice system. Subject to the availability of funding,

consideration should be given to an expansion of the availability and use of delinquency

prevention and diversion services with a focus on creating a range of community service and

education options while increasing empathy and caring in youth.

Recommendation 4: The Children’s Cabinet should continue to make a commitment to

utilizing evidence-based and promising practices to ensure that effective community

education, opportunities, support, and treatment options are available to the children, youth

and families for whom they are appropriate.

Youth Peer-to-Peer Support• Provided to a youth enrolled in a CME by a youth support

partner (YSP) who:– Assists in describing the program model– Supports the family and/or participant to participate

effectively in the Child and Family Team (CFT) meetings and in the POC development and implementation;

– Works with the Care Coordinator, participant and family to develop the plan of care; and,

– Assists in accessing services and removing barriers to care.

• Are individuals with experience with State or local services and systems as a consumer who has had emotional, behavioral or mental health challenges, are 18-26 years old, have completed the required training programs, and are employed by a Family Support Organization.

Caregiver Peer-to-Peer Support• Provided to the caregiver of a youth enrolled in a CME by a

family support partner (FSP) who:– Assists in describing the program model– Supports the family and/or participant to participate

effectively in the Child and Family Team (CFT) meetings and in the POC development and implementation;

– Works with the Care Coordinator, participant and family to develop the plan of care; and,

– Assists in accessing services and removing barriers to care.

• Are legacy family members (individuals who have current or prior experience as a caregiver of a child with Serious Emotional Disturbance (SED) or a young adult with Serious Mental Illness (SMI) who are 21 or older, have completed the required training programs, and are employed by a Family Support Organization

EBP Implementation in Maryland: Our Child and Youth Trajectory

2008, Maryland Child and Family Services Interagency Strategic Plan: Includes evidence-based and promising practices in the theme, “Continuum of Opportunities, Supports and Care:”

Specific Recommendation in the Plan: The Children’s Cabinet should continue to make a commitment to utilizing evidence-based and promising practices to ensure that effective community education, opportunities, support, and treatment options are available to the children, youth and families for whom they are appropriate.

2008, Children’s Cabinet joins efforts to improve practice and implement EBSs for children, youth and families in Maryland through funding to support implementation, fidelity and outcomes monitoring, and fiscal analysis of EBPs.

EBP IMPLEMENTATION CENTER

o Obtain data on existing EBPs in Maryland

o Conduct a “sizing” of the EBPs to determine which EBPs should be expanded or brought into the state

o Provide training on identified EBPs

o Identify funding mechanisms to support the ongoing implementation and sustainment of EBPs

o Conduct fidelity monitoring on EBP implementation

o Evaluate outcomes of EBPs

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Prioritized EBP’s

• Trauma Cognitive Behavioral Therapy

• Functional Family Therapy

• Multi Systemic Therapy

• Brief Strategic Family Therapy

• Multi Dimensional Treatment Foster Care

Be both strategic and opportunistic– Link grant and other funding/policy opportunities

together (as they arise) to build upon one another and leverage further systems change:

– CMHI Grants – MD CARES and Rural CARES– Mental Health Transformation and Block Grants– PRTF 1915(c) Demonstration Waiver– Healthy Transitions Grant (Transition-Aged

Youth)– National Child Traumatic Stress Network Grants– Children’s Bureau Grants to Child Welfare– OJJDP Grants to Juvenile Justice– State Agency Initiatives – Legislative Mandates