three branch institute on child social and emotional well-being connecticut state team meeting may...

Three Branch Institute on Child Social and Emotional Well-BeingConnecticut State Team Meeting

May 13, 2014Rocky Hill, CT

Customizing Medicaid for Children in Child Welfare

Sheila A. PiresSenior Partner, Human Service Collaborative

Core Partner, Technical Assistance Network for Children’s Behavioral HealthSenior Consultant, Child Health Quality Programs

Center for Health Care Strategies

Most children in foster care are Medicaid-eligible

Most children remain eligible for Medicaid whenthey leave foster care

• WI study – 85% remain eligible

Child welfare was not intended to be a health orbehavioral health care delivery system

Why Medicaid is Essential

Children in Foster Care Are a High Cost Medicaid Population

Represent 3.2% of children in Medicaid but 15% of children using behavioral health care

Have the highest penetration rate for use of behavioral health services than any other aid category of children (32% of children in foster care use behavioral health services compared to 26% of children on SSI, and 4.9% TANF)

Have the highest mean behavioral health expenditures of any aid category of children ($8,094 per child compared to $7,264 for children on SSI)

Have overall Medicaid mean expenditures (physical and behavioralhealth care) of $12,130 per child – costs are driven by behavioral health care

Children in foster care who use behavioral health services have costs thatare 7x higher than for Medicaid children in general

Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2013, Faces of Medicaid: Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ;Center for Health Care Strategies

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Mental Health - Costliest Health Condition of Childhood

$2.90

$3.10

$6.10

$8.00

$8.90

$0.00

$5.00

$10.00

$15.00

$20.00

$25.00

$30.00

BILL

ION

S of

Dol

lars Mental Health

Disorders

Asthma

Trauma Related ConditionsAcute BronchitisInfectious Diseases

Soni, 2009 (AHRQ Research Brief #242)

Mean Health Expenditures for Children in Medicaid UsingBehavioral Health Care*

5

All Children Using Behavioral

Health CareTANF Foster Care SSI/Disabled**

Top 10% Most Expensive

Children Using Behavioral

Health Care***

Physical Health Services $3,652 $2,053 $4,036 $7,895 $20,121

Behavioral Health Services $4,868 $3,028 $8,094 $7,264 $28,669

Total Health Services $8,520 $5,081 $12,130 $15,123 $48,790

* Includes children using behavioral health services who are not enrolled in a comprehensive HMO, n = 1,213,201** Includes all children determined to be disabled by SSI or state criteria (all disabilities, including mental health disabilities)***Represents the top 10% of child behavioral health users with the highest mean expenditures, n = 121,323

6

TANF SSI Foster Care0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%92%

5% 3%

67%

18%15%

44%

27% 29%

All Children in Medicaid* Behavioral Health Service Use**

Behavioral Health Service Expense**

Medicaid Enrollment, Behavioral Health Service Use, and Expense by Aid Category

Pires, SA, Grimes, KE, Allen, KD, Gilmer, T, Mahadevan, RM. 2013. Faces of Medicaid: Examining Children’s Behavioral Health Service Utilization and Expenditures: Center for Health Care Strategies: Hamilton, NJ

Children in Foster Care Use More Restrictive, More Expensive Services in Medicaid

More likely to use: inpatient psychiatric services,residential treatment and therapeutic group care, emergencyroom services, and psychotropic medications

Children in foster care are only one-fifth the size of theTANF population but use nearly the same amount of dollarsfor residential and group care and ER visits and 3.5 timesmore for therapeutic foster care

Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid: Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ;Center for Health Care Strategies

Children in Foster Care Have High Rates of Psychotropic Medication Use

Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid: Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ; Center for Health Care Strategies

Are 3.2% of Medicaid child population, but nearly 13% of Medicaid children using psychotropic medications

23% of children in foster care use psychotropic medications paid for by Medicaid (compared to 27% of children on SSI and 4% of TANF children)

Are more likely to receive 2 or more concurrent psychotropic medications than other aid categories of children (49% FC, 46% SSI, 26% TANF) – also 3, 4 or 5 or more

Of children getting anti-psychotics, 42% are in foster care (42% are on SSI, 18% are TANF)

Have highest mean expenditures for psychotropic medications of any aid category of children ($934 FC, $916 SSI, $475 TANF)

Chronic Physical Health Conditions Among Children in Medicaid Using Behavioral Health Services*

• 38% of children with BH claims also had claims for at least one chronic medical condition…but

• Pulmonary diseases were the most common physical health condition (overall mean expense of $1,091)

• High-cost medical conditions (e.g. cancer at $19,065) had low frequency

*Using Chronic Disability Payment System (CDPS) Methodology

9Pires, SA, Grimes, KE, Allen, KD, Gilmer, T, Mahadevan, RM. 2013. Faces of Medicaid: Examining Children’s Behavioral Health Service Utilization and Expenditures: Center for Health Care Strategies: Hamilton, NJ

What Especially Drives Medicaid Costs (and often poor outcomes) for Children in Foster Care?

• Use of emergency room for regular careStrategy: Medical home, WI

• Use of emergency room for asthma-related issuesStrategies: (See “Achieving Better Care for Asthma: A BCAP Toolkit” http://www.chcs.org/publications3960/publications_show.htm?doc-id=20896

• Inappropriate Use of Psychotropic MedicationsStrategies: Red flag monitoring (too young, too many, too much)and consultation to/education of prescribers as in OR and WY;Psychiatric consultation to primary care docs as in MA (MCPAP);Informed consent supported by access to psychiatric consultationas in IL and VT

Pires, S. 2013. Washington DC: Human Service Collaborative

http://www.chcs.org/publications3960/publications_show.htm?doc-id=20896


• Use of Residential Treatment (and Day Treatment)Strategy: Effective home and community-based alternativesand intensive care coordination using fidelity Wraparound as in MA, NJ, WI

• Use of traditional outpatient therapies“Based on current evidence of the effectiveness of interventions in community mental health settings, there is no reason to assume that the outpatient mental health services provided to foster children are effective in improving outcome” (James, S., Landsverk, J., Slymen, D. and Leslie, L.Predictors of Outpatient Mental Health Service Use—The Role of Foster Care Placement ChangeMent Health Serv Res. 2004 September; 6(3): 127–141)

“Results indicate that children who have experienced long-term foster care do not benefit from the receipt of outpatient mental health services” (Bellamy, J., Gopala, G., Traube, DA national study of the impact of outpatient mental health services for children in long-term foster care. Clin Child Psycholog Psychiatry 2010 Oct;15(4):467-79)



• Duplication of Services (e.g., multiple assessments,multiple care coordination)Strategies: common screening/assessment tools; fidelity Wraparound approach with dedicated care coordinator, low ratios (1:10)

• Longer lengths of stay and multiple placements infoster care associated with higher Medicaid costsStrategies: fidelity Wraparound, Family Finding, Strengthening Families, others


Lessons from States: Customization for Children in Foster Care in Medicaid

Medicaid service delivery and payment models need to reflect attention to state child welfare, Medicaid and behavioral health system policies and goals –

Collaborative planning, design, implementation needed

Explore potential for Medicaid match from child welfare –most children are Medicaid eligible; many services paid for bychild welfare are Medicaid-allowable (NJ, AZ, MI)

State agencies need to approach implementation in partnership with managed care entities

Pires, S. & Stroul, B. 2013. Making Medicaid Work for Children in Child Welfare. Hamilton, NJ: Center for Health Care Strategies

Trauma-Informed Screening and Early Intervention(3/27/13 CMCS and SAMHSA Informational Bulletin and 7/11/13 SMD Letter)

Mandate use of standardized screening tools and inclusion of behavioral and developmental (not only physical health) screens (MA)

Incorporate state child welfare requirements for physical, behavioral and dental health screens within specified timeframes

AZ: Urgent response requiring behavioral health screen within 72 hrs of entering care and “fast track” linkage to services

MA: Medical screening required within 7 days and comprehensive exam within 30 days, including behavioral health/use of standardized tools

Require inter-periodic screens when child enters foster care, or changes placement, or tied to length of stay in foster care

Quality payments for providers meeting trauma-informed standards

May require enhanced rate (MA)


Customization Strategies – Regardless of System Design

Customization Strategies – Regardless of System DesignService Coverage

(May 7, 2013 CMCS and SAMHSA Informational Bulletin)

Cover a broad array of behavioral health home and community-based services MA: In-home services; family peer support; mobile response; therapeutic mentoring; behavior management therapy and monitoring; intensive care coordination using a Wraparound approach

NJ: Mobile response and stabilization; therapeutic group home care; treatment homes/therapeutic foster care; intensive care management; Wraparound process; behavioral assistance; intensive in-home/community

services; transportation; youth support and development

Cover a range of crisis options, including a newer generation model of mobile response and stabilization and telebehavioral health capacity (WI, NJ, MA)

Cover evidence-based practices, e.g. Trauma-Focused Cognitive Behavioral Therapy , Multisystemic Therapy, Functional Family Therapy, Multidimensional Treatment Foster Care (growing number of states)


Customization Strategies – Regardless of System DesignPsychotropic Medications

(8/24/12 and 11/23/2011 CMCS Informational Bulletin and 11/21/11 State Medicaid Directors Tri-Agency Letter on Appropriate Use of Psychotropic Medications Among Children in Foster Care)

Track and monitor outlier use, e.g. too young, too many, too much (growing number of states like WY, MD) – interface with Drug Utilization Review Board

Provide consultation to prescribers, including primary care providers (MA, VT)

Orient MCOs to state’s informed consent and assent policies in child welfare

Provide coverage and training for treatment alternatives(aggression, sleep disorders)

Pires, S. 2013 Human Service Collaborative: Washington DC

Customization Strategies – Regardless of System DesignProvider Network

Include providers knowledgeable about the child welfare population• AZ: sexual abuse, trauma• MA: state required same network of providers across all MCOs for• behavioral health home and community-based services (Rosie D);• requirements for expertise in trauma-informed care• TN: Best Practices Network

Develop protocols and practice guidelines related to children in foster care and interface with child welfare system

• AZ: how to work with the child welfare agency and the courts; clinical needs of the child welfare population

Broaden the Medicaid provider network and include: providers trained in co-occurring mental health and substance use, EBPs, trauma-informed care; racially/ethnically diverse providers; inclusion of families/youth with lived experience as providers; knowledgeable about child welfare system (NJ, MA, AZ)

Enhance rates for providers trained in EBPs and trauma-informed care


Customization Strategies – Regardless of System Design Values-Based, Goal-Oriented Utilization Management Criteria

Access: require no prior authorization for basic behavioral health outpatient services up to certain limit (MA)

Coordinated Care: require that plans of care developed through Wraparound process determine medical necessity (with outlier management) (AZ, MA, NJ, LA)

Require no “fail first” criteria to access services or medications – move away from “levelsof care” to strengths-based, standardized assessments (e.g. CANS) (NJ, MA)

Prior auth for certain psychotropic meds, e.g. antipsychotics for young children (MD)


Customization Strategies – Regardless of System DesignOrientation and Training

Incorporate orientation/training for MCOs and providers on children with significant behavioral health challenges, foster care population, child welfare system, role of court (MA)

Incorporate training for Medicaid providers on effective practices• Wraparound approach (MA, MI, NJ, LA, MD)

• Trauma-Focused CBT and Parent Management Training-OregonModel (MI)

• Trauma-informed care (AZ, MA)• Screening tools (MA)

• Managing and Adapting Practice (MAP) (CA)


Customization Strategies – Regardless of System DesignData and Performance Requirements

Specific tracking and reporting of: • Child behavioral health penetration rates and utilization (services and medications)

stratified by age, gender, race/ethnicity, aid category, region, diagnosis, service type, medication type.

• Performance expectations (not only HEDIS)AZ: PH-access to primary care, adolescent well care visits, annual dental

visits, immunization measures; BH-emotional regulation, avoidingdelinquency, stability of living situation, substance abstinence, children in

psych hospitals awaiting placementsMI: BH-reduced use of residential treatment, maintenance in the

community, improved functioning using Child/Adolesc Functional Assessment Scale (CAFAS)NJ: PH-timeliness of assessments and comprehensive exams; exams

in compliance with EPSDT guidelines; semi-annual dental checks;immunization measures; BH-access to BH services following EPSDT

assessment; clinical and functional outcomes using Child/Adolesc Needs and Strengths (CANS)Pires, S. & Stroul, B. 2013. Making Medicaid Work for Children in Child Welfare. Hamilton, NJ: Center for Health Care Strategies

Customization Strategies – Regardless of System DesignAdministrative and Financing

Risk-adjust rates for children in child welfare and children with serious behavioral health challenges (AZ)

Utilize population case rates for high utilizing child populations (WI, IL) Incorporate special liaison in MCOs for child welfare-involved children, children enrolled in

Wraparound, youth transitioning, and hold periodic meetings with child welfare and MCOs for trouble-shooting and quality improvement

Incorporate a quality review process that involves families and youth with lived experience on quality review teams and requires input from other child systems (e.g. child welfare).

Hire/contract with family organizations to serve as family advocate; requirements for MCOs to involve families and youth in staff and advisory capacities.

Require reinvestment back into child home and community services.Capacity to train, coach and develop the capacity of providers, administrators, staff,

families/youth to implement desired reforms.


Customization Strategies – Regardless of System DesignOther Administrative Supports

“Warm line” for child welfare workers and caregivers

It is also very helpful to have child health units or designated staff in child welfare to interface with MCOs; Medicaid administrative case management and Title IV-E can both be used to help finance this capacity (NJ, UT)


Customization Strategies – Regardless of System DesignCustomized Intensive Care Coordination(May 7, 2013 CMCS and SAMHSA Informational Bulletin)

Incorporate intensive care coordination using Wraparound approach for children with serious behavioral health challenges (growing number of states – MA, LA, NJ; PRTF Waiver Demo;CHIPRA Care Management Entity Quality Collaborative states)

• Intensive care coordination rates for this population range from $780 pmpm to $1300 pmpm (CHCS Matrix)

• In fidelity intensive care coordination/Wraparound approaches, all-inclusive cost of care (e.g., admin, care coord, placements, clinical treatment, informal supports) averages $3700-$4200 pmpm (about $2100 is Medicaid)– compare to $9,000 pmpm in PRTFs, higher in psych inpatient

Require that every child has a designated primary care provider - e.g., medical home - and coordination between physical and behavioral health care providers


Analysis of Medical Home Services for Children with Significant Behavioral Health Conditions

“All behavioral health conditions except ADHD associated with difficulties accessingspecialty care through medical home”

“The data suggest that the reason why services received by children and youth with behavioral health conditions are not consistent with the medical home model

has more to do with difficulty in accessing specialty care than with accessingquality primary care”.*

*Sheldrick, RC & Perrin, EC. “Medical home services for children with behavioral health conditions”. Journal of Developmental Pediatrics, 2010 Feb-Mar 31 (2) 92-9

Need for more intensive care coordination approaches forchildren with significant behavioral health conditions

Care Management EntitiesOrganizations providing intensive care coordination atlow ratios (1:10) using high quality Wraparound approach

High Quality Wraparound Teams providing intensivecare coordination at low ratios embedded in supportiveorganization, such as CMHC, FQHC or school-based mental health center

Customized Care Coordination Approaches for Children with Serious Behavioral Health Challenges

Redirecting High Cost, Poor Outcome Spendingthrough Care Management Entities/High Quality

Wraparound Teams

Strategies:• Redirect dollars from high cost/poor outcome services (e.g., residential,

detention, group homes)

• Invest savings per youth served in home and community-based service capacity

• Promote diversification/”re-engineering” of residential treatment centers

• Population-based all-inclusive case rates or bundled care coordination rates

• Population-focused quality and outcome indicators

• Population-based purchasing approaches tied to performancePires, S. 2010. Human Service Collaborative

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Wraparound Milwaukee (1915 a)

Wraparound Milwaukee. (2010). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and Adolescent Services Branch.

CHILD WELFAREFunds thru Case Rate

(Budget for InstitutionalCare for Children-CHIPS)

JUVENILE JUSTICE(Funds budgeted for

Residential Treatment forYouth w/delinquency)

MEDICAID CAPITATION($1557 per month

per enrollee)

MENTAL HEALTH• Crisis Billing• Block Grant

• HMO Commercial Insurance

Wraparound MilwaukeeCare Management Organization

$47MPer Participant Case Rates fromCW ,JJ and ED range from about$2000 pcpm to $4300 pcpm

Intensive Care Coordination

Child and Family TeamProvider Network210 Providers70 Services

Plan of Care

11.0M 11.5M 16.0M 8.5M

Families United$440,000

SCHOOLSyouth at risk for

alternative placements

Mobile Response & Stabilization co-funded by schools, child welfare, Medicaid & mental health

All inclusive rate (services, supports, placements, care coordination, family support) of $3700 pcpm; care coordination portion is about $780 pcpm

Use CANS

Wisconsin Foster Care Medical Home andWraparound Milwaukee Interface

Foster Care Medical Home:

Children’s HospitalWraparound Milwaukee

• Designated primary care provider• Coordination of medical care• Coordination with behavioral health

• Credentialing of BH providers for Children’s• Mobile response and stabilization services• Intensive care coordination using fidelity Wraparound for children with significant behavioral health conditions

UMDNJ Training & TA Institute

Department of Children and FamiliesDivision of Children's System of Care (CSOC)

Dept. of Human ServicesDivision of Medical

Assistance and Health Services (Medicaid)

BH, CW, MA $$ - Single Payor

Provider Network

Contracted Systems Administrator- PerformCare – ASO for child BH carve out

• 1-800 number• Screening• Utilization management• Outcomes tracking

Medicaid and DCF-certified providers

Family peer support,education and advocacyYouth movement

Lead non profit agencies managingchildren with serious challenges, multisystem involvement

New Jersey (Rehab Option and TCM)

*Care Management Entities- CMOs

Family SupportOrganizations

*Care coordination rate of $1034 pcpm

Mobile Response & Stabilization Services

Adapted from State of New Jersey 2010

Use CANS

Health Home

Louisiana (1915 b and 1915 c waivers)

State Purchaser –

Medicaid and BHContracting

Claims processingPayment of providers

Training andCapacity building

Statewide Management

Organization (ASO) - Magellan Registration

Determination of appropriateness Ongoing services auth

Population level tracking/UM/UR/Quality assurance/Outcomes management/monitoring

*Regional Care Management

Entities – non profit specialty providersScreening, intake, initial service auth

child and family teamsintensive care management,

connection to natural supports Indiv level tracking/UM/UR/Quality assurance/

Outcomes management/monitoringShared MIS with SMO

Local Providers andNatural Supports

Family SupportOrgs. – family-run

Provide/build capacity forParticipation in policy making and Quality improvement at all levels,

Participation in child/family teams, Family liaisons,

Family educators, Youth peer mentors

manage provider network

support as needed from ASO

work w ASO to fill provider gaps

Interagency Governance

*Care coordination rate of $1035 pcpmState of Louisiana. 2011

Use CANS

Child Welfareadded dollars

Massachusetts (1115 Waiver, State Plan Amendment, TCM)

MCO MCO MCO MCO PCCM BHO

State Medicaid Agency - Purchaser

*Locally-Based Care Management Agencies (called Community Services Agencies) – Non Profit BH and Specialty

Providers

• Ensure Child & Family Team Plan of Care• Provide Intensive Care Coordination• Provide peer supports and link to natural helpers• Manage utilization , quality and outcomes at service level

Standardized tools for screening and assessment by PCPs

*Care Coordination Rate: Massachusetts does not use a PMPM rate. However, for comparative purposes , (if assuming a productivity standard of approximately 26 hours a week, and an average caseload of 10), the 15-minute rate for Care Coordination and Family Support &Training may appear to suggest a PMPM of $1,100 - $1,200.

Use CANS

32

High Quality Wraparound Team as Health TeamOklahoma (Sec. 2703 SPA)

Community Mental Health Center

Health Team for Health Team forAdults with SMI: Children with SED:

Nurse Care Manager Wraparound FacilitatorACT Team Intensive Care Coord.Adult Peer Consumer Family and youth peer

support Improve quality and cost of care

Medicaid Vehicles to Support Customized IntensiveCare Coordination Using Fidelity Wraparound

With population pmpm case rate or with care coordination pmpm rate

• 1915 a – Wraparound Milwaukee, Children Come First (Dane Co WI)• Targeted Case Management – NJ, MA• 2703 Health Home SPA – OK (for SED), NJ (for subset of children with SED andco-occurring medical or developmental conditions• 1915b/c – LA• 1915 i – MD• Money Follows the Person (GA)• Balancing Incentive Program (GA)• CMMI Health Innovations Grant (CHCS and 4-state application)• 1905 (a), 1905 (t)(1) - ??

Child and Youth Populations Typically Served by CMEs/High Quality Wraparound Teams

•Children & adolescents with serious emotional & behavioral challenges at risk of out-of-home placement or in residential treatment, group homes and other institutional settings

•Youth at risk of incarceration or placement in juvenile correctional facilities

• Other populations of children in child welfare (e.g. at risk of placement disruption)

•Children & adolescents returning from institutional placements in residential treatment, correctional facilities or other out-of-home setting

•Children & adolescents at risk of or returning from psychiatric inpatient settings

•Detention diversion and alternatives to formal court processing for juveniles

•Other populations (e.g., youth at risk for alternative school placements)Pires, S. 2010. Human Service Collaborative

Paid by Per DeimAve Per Diem Rate

3/14Placements on 3/31/14

In-State RTCJuvenile Justice 445.41 29Behavioral Health 407.46 136

Out of State RTCJuvenile Justice 266.51 2Behavioral Health 718.02 24

DCF Licensed Group Homes 489.76 88Other Agency Licensed Group Homes 366.51 37Transitional Living Apt. Program (TLAP) # 326.83 13Supportive Work Education & Training 256.24 27

Paid Quartely by POS Contract Ave Per Diem RateCrisis Stablization 382.38 3Theraputic Group Homes 499.89 173JJ Theraputic Group Homes 451.07 5JJ Substance Abuse Treatments 123.33 1Safe Home 344.72 36STARS 339.64 61

$13,362/pypm$12,224 pypm

$7995 pypm$21,541 pypm

$14,693 pypm$10,995 pypm

$14,997 pypm$13,532 pypm

Connecticut Congregate Care Costs

Care Management Entity Functions

At the Service Level:Child and family team facilitation using fidelity Wraparound practice modelScreening, assessment, clinical oversightIntensive care coordinationCare monitoring and reviewPeer support partnersAccess to mobile crisis supports

At the Administrative Level:Information management – real time data; web-based ITProvider network recruitment and management (including natural

supports)Utilization managementContinuous quality improvement; outcomes monitoringTraining

Pires, S. 2010. Human Service Collaborative

Variation in Types of CME Entities

•Public agency as CME – Wraparound Milwaukee

•New non profit organization with no other role – New Jersey Care Management Organizations

•Existing non profit organization with other direct service capability – Massachusetts Community Service Agencies

•Hybrid – Non profit organization with other direct service capability in formal partnership with neighborhood organization – Cuyahoga County, OH Coordinated Care Partnerships

•Non profit HMO – Massachusetts Mental Health Services Program for Youth

Pires, S. 2010. Human Service Collaborative

Coordination with Primary Care in a Wraparound Approach

Care Management Entity or Wraparound Health Team is responsible for:

Ensuring child has an identified primary care provider (PCP)

Tracking of whether child receives EPSDT screens on schedule

Ensuring child has at least an annual well-child visit

Communicating with PCP opportunity to participate in child and family team and ensuring PCP has child’s plan of care and is informed of changes

Ensures PCP has information about child’s psychotropic medication andthat PCP monitors for metabolic issues such as obesity and diabetes

Pires, S. 2013. Customizing Health Homes for Children with Serious Behavioral Health Challenges. Hamilton, NJ; Center for Health Care Strategies

How the Financing Works

Example:• 800 youth are in RTCs at any given time• ALOS = 12 mos.• RTC stay costs $10,000 per youth, per month on

average• For 800 youth, spend $96m. per year on RTCs • 4/5 of the youth are involved with child welfare

and juvenile justice and 1/5 of the children non-system involved


COST ASSUMPTIONS

Assume cost of $5,000 pmpm* for Care Management Entities, with costs distributed as follows:• Assume 22% for care management ($1100 pmpm)• Assume 10% for management infrastructure ($500 pmpm)• Assume 68% for services and supports ($3,400 pmpm)

Assume need for 2% risk pool ($100 pmpm)

(*Note that Wrap Milwaukee operates on about $3900pmpm for these same functions and does not have arisk pool)

Total Needed: $5100 pmpm ($49 m total)


Available Re-Directed Dollars:

Medicaid covers: $2805 pmpm (55% of the cost – represents therapeutic costs in RTC) x 640 children = $21.5m

Child welfare and Juvenile Justice cover: $2295 pmpm (45% of the cost – represents room, board, watchful oversight costs in RTC) x 640 children = $17.6m

Mental health covers: $5100 (full costs for non-system, non Medicaid eligible children) x 160 children = $9.8m

Total Financing = $49m

Projected Reinvestment Dollars: $4900 pmpm x 800 children = $47 m

FINANCING ASSUMPTIONS


Wraparound with fidelity is increasingly considered “evidence based”

• State of Oregon Inventory of EBPs• California Clearinghouse for Effective Child Welfare

Practices• Washington Institute for Public Policy: “Full fidelity

wraparound” is a research-based practice

Bruns, E. National Wraparound Initiative

43

What is the research base?Ten Published Controlled Studies of Wraparound

Study Target population Control Group Design N

1. Hyde et al. (1996)* Mental health Non-equivalent comparison 69

2. Clark et al. (1998)* Child welfare Randomized control 132

3. Evans et al. (1998)* Mental health Randomized control 42

4. Bickman et al. (2003)* Mental health Non-equivalent comparison 1115. Carney et al. (2003)* Juvenile justice Randomized control 1416. Pullman et al. (2006)* Juvenile justice Historical comparison 2047. Rast et al. (2007)* Child welfare Matched comparison 678. Rauso et al. (2009) Child welfare Matched comparison 2109. Mears et al. (2009) MH/Child welfare Matched comparison 121

10. Grimes at el (2011) Mental health Matched comparison 211

*Included in 2009 meta-analysis (Suter & Bruns, 2009)

Effects of Wraparound Are Significant

Bruns, E. National Wraparound Initiative

Reduced Costs and Out-of-Home Placements

Wraparound Milwaukee • Reduction in placement disruption rate in child

welfare from 65% to 30%• School attendance for child welfare-involved

children improved from 71% days attended to 86% days attended

• 60% reduction in recidivism rates for delinquent youth from one year prior to enrollment to one year post enrollment

• Decrease in average daily population in residential treatment centers from 375 to 50• Reduction in psychiatric inpatient days from 5,000

days per year to less than 200 • Average monthly cost of $4,200 (compared to

$7,200 for RTC, $6,000 for juvenile detention, $18,000 for psychiatric hospitalization)

Milwaukee County Bureau of Children’s Behavioral Health. 2010

45

• Experienced 30% net reductions in Medicaid spending , comprisedof decreases in PRTF andinpatient psychiatric withincreases in targeted casemanagement and home andcommunity servicesBruns, E. 2011

New Jersey• The state has saved$40m in psychiatric inpatientexpenditures over last threeyears and 15% reduction inresidential treatmentHancock, B. NJ Division of Child Behavioral Health. 2010

Maine

GeorgiaMedicaid annual average cost for a CME youth is $44,008 less than average annual cost for PRTF youth (CME = $34,398, PRTF =$78,406)

Comparing youth out-of-home placements in the 6 months pre-CME engagement to the 3-8 months post-CME engagement showed:

86% reduction in inpatient hospitalization for CME youth meeting PRTF waiver criteria89% reduction in inpatient hospitalization for other high need youth enrolled in CME73% reduction in PRTF stays for CME youth meeting PRTF waiver criteria 62% reduction in PRTF stays for other high need youth enrolled in CME

MarylandCost of serving PRTF Waiver youth in the CME is 35% of the cost of serving youth in PRTFs

Reduced Costs and Out-of-Home Placements


Costs and residential outcomes are robust• Controlled study of MHSPY program in Massachusetts (Grimes

2011)• 32% lower emergency room expenses • 74% lower inpatient expenses than matched youths

• CMS Psychiatric Residential Treatment Facility (PRTF) Waiver Demonstration project (Urdapilleta et al., 2011)

• Average per capita saving by state ranged from $20,000 to $40,000

• Los Angeles County DSS found 12-month placement costs were $10,800 for Wraparound-discharged youths compared to $27,400 for matched group of RTC youths


Opportunities in Medicaid Informational Bulletin

Covering Home- and Community-Based Mental Health Services Under Medicaid

Informational Bulletin

Issued jointly by the Centers for Medicare and Medicaid Services and the Substance Abuse and Mental Health Services Administration in May 2013

Purpose to assist states to design a benefit that will meet the needs of children, youth, and young adults with significant mental health conditions

http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-05-07-2013.pdf













































































Data Base for Informational Bulletin

Outcomes from Systems of Care funded by Substance Abuse and Mental Health Services Administration’s (SAMHSA) Children’s Mental

Health Initiative (CMHI)

Outcomes from CMS Psychiatric Residential Treatment Facility (PRTF) Waiver Demonstration Program

Benefit Design

Intensive Care Coordination: Wraparound Approach

Parent/Youth Peer Support Services

Intensive In-Home Services Respite

Mobile Crisis Response and Stabilization Flex Funds

Intensive Care Coordination: Wraparound Approach

• Assessment and service planning

• Accessing and arranging for services

• Coordinating multiple services

• Access to crisis services

• Assisting the child and family to meet basic needs

• Advocating for the child and family

• Monitoring progress

Need low care coordinator:child/family ratios (1:10)

• Team-based process to develop and implement individualized care plans

• Focuses on all life domains

• Includes clinical interventions and formal and informal supports

• Wraparound “facilitator” is a dedicated care coordinator who organizes, convenes, and coordinates the process

• Child and family team for each youth that includes the child, family members, involved providers from child-serving agencies, key members of the child’s formal and informal support network

Intensive Care Coordination Wraparound Approach

Intensive In-Home Services• Combination of therapy and

behavioral consultation from licensed clinicians and skills training and support from paraprofessionals

• Small caseloads to allow team to work with the child and family intensively

• Therapeutic interventions delivered in homes and other community settings

• Improve youth and family functioning and prevent out-of-home placement in inpatient or residential treatment settings

• Typically delivered by a team • Gradual transition to other formal and

informal services and supportsComponents

• Individual and family therapy• Skills training • Behavioral interventions

Peer Services: Parent and Youth Support Services

• Providers of peer support services are family members or youth with “lived experience” who have personally faced the challenges of coping with serious mental health conditions, either as consumer or caregiver

• Provide support, education, skills training, and advocacy in ways that are both accessible and acceptable to families and youth

Peer Support Services Include:

• Developing and linking with formal and informal supports

• Instilling confidence• Assisting in the

development of goals• Serving as an advocate,

mentor, or facilitator for resolution of issues

• Teaching skills necessary to improve coping abilities

Respite Services

• Intended to assist children with living in their homes and community

• Temporarily relieve primary caregivers to promote child well-being

• Provide safe and supportive environments on a short-term basis

• Provided either in the home or in approved out-of- home settings

Mobile Crisis Response and Stabilization Services

• Defuse and de-escalate difficult mental health situations

• Prevent unnecessary out-of-home placements, particularly hospitalizations

• Provided in the home or any setting where crisis is occurring

• Crisis stabilization period with transition to ongoing services

• One-to-one crisis stabilizers

Crisis Team

• 24/7 mobile crisis response in home and community

• Typically a two-person team is on call and available to respond

• May be comprised of professionals and paraprofessionals (including peer support) providing training in crisis intervention skills

• Works with child and family to resolve immediate crisis

• Helps them identify potential triggers and strategies to deal with future crises

Flex Funds: Customized Goods and Services

• Purchase non-recurring set-up expenses (furniture, bedding, clothing)• One-time payment of utilities, rent or other expenses as long as the youth and

family demonstrate the ability to pay future expenses• Academic coaching, memberships to local girls or boys clubs, etc. • Particularly useful when a youth is transitioning from residential treatment

setting to family or independent living• Available to individuals participating in various Medicaid waivers and/or the

1915(i) program

Trauma-Informed Systems and Evidence-Based Trauma Treatments

• Increased awareness of the impact of trauma• Children and youth with most challenging mental health needs often have

experienced significant trauma

Adverse Childhood Experience Study (ACES)

• Reported short and long-term outcomes of childhood exposure to trauma including mental health, health and social problems

States (CT) are providing training and coaching for clinicians in evidence-based practices such as TF-CBT

States are exploring new policies and practices for trauma-informed systems of care that will be less likely to re-traumatize children and youth

Other Home- and Community-Based Services

• States have also developed service definitions for a variety of additional home and community-based services

• Can be provided through State Plan Amendment, 1915(c) waivers and the 1915(i) program

Additional Services

• Therapeutic mentoring• Supported employment for

older youth• Mental health consultation

services

Importance of Informational Bulletin

For State Medicaid Agencies

For State and Local Mental Health and

Substance Abuse Agencies

For Providers

For Family Advocacy Efforts

For Youth and Young Adults

For State and Local Child

Welfare Agencies

Flexibility in Medicaid Program • States have significant flexibility in Medicaid program to cover mental health and substance use services for

youth with significant mental health conditions

For Family Members Who Are Not Medicaid-Eligible

• Access to insurance coverage through Health Exchanges• Elimination of annual and lifetime limits on benefits• No denial of coverage for pre-existing conditions• No cost-sharing/co-pays for certain preventive services(based on IOM recommendations; important for Medicaid populations as well)

• Well-woman visits• Gestational diabetes screening• HPV DNA testing• Counseling for sexually transmitted infections• HIV screening and counseling• Contraception and contraceptive counseling• Breastfeeding support, supplies and counseling• Interpersonal and domestic violence screening and counseling


Example: Addressing Parental Substance Abuse

Medicaid• Cover substance use disorder services (adults who are eligible for Medicaid can access)• Cover evidence-informed interventions for Medicaid child that incorporate family engagement, education and support• Cover 1:1 crisis stabilizers for child (WI)• Cover family and youth peer support (8 states as State Plan service)

Child welfare• IV-E waiver (for adults who are not Medicaid-eligible and for non-Medicaid covered services)

Mental Health and Substance Abuse• Block grant funding for adults not Medicaid-eligible or services not covered by Medicaid

TANF – can be used for substance use counseling and linkage to services (not treatment)


7/11/13 State Medicaid Director’s Tri-Agency Letter onTrauma-Informed Treatment http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-07-11.pdf

5/7/13 Informational Bulletin on Coverage of Behavioral Health Services for Children,Youth and Young Adults with Significant Mental Health Conditionshttp://www.medicaid.gov/federal-policy-guidance/downloads/CIB-05-07-2013.pdf

3/27/13 Informational Bulletin on Prevention and Early Identification of MentalHealth and Substance use Conditionshttp://www.medicaid.gov/federal-policy-guidance/downloads/CIB-03-27-2013.pdf

8/24/12 Informational Bulletin on Resources Strengthening the Management of Psychotropic Medications for Vulnerable Populationshttp://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-08-24-12.pdf

11/21/11 State Medicaid Directors Tri-Agency Letter on Appropriate Use ofPsychotropic Medications Among Children in Foster Carehttp://www.medicaid.gov/federal-policy-guidance/downloads/SMD-11-23-11.pdf

Federal Medicaid Guidance

http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-07-11.pdf

http://www.medicaid.gov/federal-policy-guidance/downloads/CIB-05-07-2013.pdf

http://www.medicaid.gov/federal-policy-guidance/downloads/CIB-03-27-2013.pdf


http://www.medicaid.gov/federal-policy-guidance/downloads/SMD-11-23-11.pdf

Resources

Making Medicaid Work for Children in Child Welfare: Examples from the Fieldhttp://www.chcs.org/usr_doc/Making_Medicaid_Work.pdf

Customizing Health Homes for Children with Serious Behavioral Health Challengeshttp://www.chcs.org/usr_doc/Customizing_Health_Homes_for_Children_with_Serious_BH_Challenges_-_SPires.pdf

Psychotropic Medications Quality Improvement Collaborative:Improving the Use of Psychotropic Medications Among Children in Foster Carehttp://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1261326

CHIPRA Care Management Entity Quality Collaborativehttp://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1250388

National Wraparound Initiative http://www.nwi.org

http://www.chcs.org/usr_doc/Making_Medicaid_Work.pdf

http://www.chcs.org/usr_doc/Customizing_Health_Homes_for_Children_with_Serious_BH_Challenges_-_SPires.pdf

http://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1261326

http://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1250388

http://www.nwi.org/

At 12, Jacob was removed from his father’s home due to neglect and was placed with an aunt in another town. Jacob began using drugs and skipping school. His aunt talked to her child welfare case worker about getting Jacob substance abuse counseling and also thought that a male adult mentor would be good for him. However, traditional Medicaid did not cover substance abuse services or therapeutic mentors, and the child welfare system’s budget had been cut, making access to these services through child welfare also difficult. Jacob became increasingly angry and aggressive toward his aunt, and after threatening her with a knife, was held at the juvenile detention center. While there, Jacob attempted suicide. He was hospitalized in an adolescent psychiatric unit for a week, placed on psychotropic medications, and discharged to a residential treatment center after his aunt refused to take him back without community-based services. Jacob remained in the residential facility for nine months, and was then discharged to a foster home. The one-year cost of his detention, hospitalization, medications and residential stay totaled $67,900, $48,000 of which was paid for by Medicaid.

Contrast Jacob’s story with that of Jeremy, also removed from home at age 12 and placed with a relative, and having a similar history of substance use, skipping school, anger, aggression, and alternating threats to kill his grandmother or himself. Jeremy, however, was enrolled in a Medicaid waiver program allowing access to substance abuse treatment, therapeutic mentoring, and a Wraparound process that provided him with a care coordinator and his grandmother with a family partner to provide peer support. They were both involved in a structured, strengths-based Wraparound process to find community-based approaches and solutions to the problems Jeremy was experiencing. The waiver services Jeremy and his grandmother received over the course of a year – therapeutic mentoring, substance abuse counseling, and Trauma-Focused Cognitive Behavioral Therapy for Jeremy, family peer support for his grandmother, care coordination, and use of a small amount of flexible funds to pay for a boxing gym membership paid for by child welfare totaled $21,740 in costs to Medicaid. Jeremy remains in the community with his grandmother.

*Note. These are not actual case vignettes; they are representative to illustrate the differences for children as a result of state efforts to strengthen Medicaid for children in child welfare.

At 12, Jacob was removed from his father’s home due to neglect and was placed with an aunt in another town. Jacob began using drugs and skipping school. His aunt talked to her child welfare case worker about getting Jacob substance abuse counseling and also thought that a male adult mentor would be good for him. However, traditional Medicaid did not cover substance abuse services or therapeutic mentors, and the child welfare system’s budget had been cut, making access to these services through child welfare also difficult. Jacob became increasingly angry and aggressive toward his aunt, and after threatening her with a knife, was held at the juvenile detention center. While there, Jacob attempted suicide. He was hospitalized in an adolescent psychiatric unit for a week, placed on psychotropic medications, and discharged to a residential treatment center after his aunt refused to take him back without community-based services. Jacob remained in the residential facility for nine months, and was then discharged to a foster home. The one-year cost of his detention, hospitalization, medications and residential stay totaled $67,900, $48,000 of which was paid for by Medicaid.

Contrast Jacob’s story with that of Jeremy, also removed from home at age 12 and placed with a relative, and having a similar history of substance use, skipping school, anger, aggression, and alternating threats to kill his grandmother or himself. Jeremy, however, was enrolled in a Medicaid waiver program allowing access to substance abuse treatment, therapeutic mentoring, and a Wraparound process that provided him with a care coordinator and his grandmother with a family partner to provide peer support. They were both involved in a structured, strengths-based Wraparound process to find community-based approaches and solutions to the problems Jeremy was experiencing. The waiver services Jeremy and his grandmother received over the course of a year – therapeutic mentoring, substance abuse counseling, and Trauma-Focused Cognitive Behavioral Therapy for Jeremy, family peer support for his grandmother, care coordination, and use of a small amount of flexible funds to pay for a boxing gym membership paid for by child welfare totaled $21,740 in costs to Medicaid. Jeremy remains in the community with his grandmother.

*Note. These are not actual case vignettes; they are representative to illustrate the differences for children as a result of state efforts to strengthen Medicaid for children in child welfare.

Illustrating the Impact of State Efforts: Jacob and Jeremy*


For further information, contact:

Sheila A. [email protected]

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